Provider Demographics
NPI:1699300822
Name:LAKE NORMAN MEDICAL, PLLC
Entity type:Organization
Organization Name:LAKE NORMAN MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-495-2470
Mailing Address - Street 1:1661 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3519
Mailing Address - Country:US
Mailing Address - Phone:704-495-2470
Mailing Address - Fax:
Practice Address - Street 1:1661 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3519
Practice Address - Country:US
Practice Address - Phone:704-495-2470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty