Provider Demographics
NPI:1699867051
Name:LAKE COUNTY
Entity type:Organization
Organization Name:LAKE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLOMEDA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:406-883-7288
Mailing Address - Street 1:106 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2133
Mailing Address - Country:US
Mailing Address - Phone:406-883-7288
Mailing Address - Fax:406-883-7290
Practice Address - Street 1:802 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-3201
Practice Address - Country:US
Practice Address - Phone:406-883-7288
Practice Address - Fax:406-883-7290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT251B00000X, 261QF0050X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No251B00000XAgenciesCase Management
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT31308OtherBLUE CROSS BLUE SHIELD
MT3502109Medicaid
MT3502109Medicaid