Provider Demographics
NPI:1598505364
Name:COUNTY OF LAKE
Entity type:Organization
Organization Name:COUNTY OF LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES MA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-274-9101
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458-1024
Mailing Address - Country:US
Mailing Address - Phone:707-998-0310
Mailing Address - Fax:
Practice Address - Street 1:13300 E HIGHWAY 20 STE O
Practice Address - Street 2:
Practice Address - City:CLEARLAKE OAKS
Practice Address - State:CA
Practice Address - Zip Code:95423-9436
Practice Address - Country:US
Practice Address - Phone:707-998-0310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-29
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17EZMedicaid