Provider Demographics
NPI:1174516249
Name:LAKE CONVENIENCE CLINIC
Entity type:Organization
Organization Name:LAKE CONVENIENCE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-398-1560
Mailing Address - Street 1:100 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-8690
Mailing Address - Country:US
Mailing Address - Phone:573-348-1560
Mailing Address - Fax:573-348-5088
Practice Address - Street 1:100 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-8690
Practice Address - Country:US
Practice Address - Phone:573-348-1560
Practice Address - Fax:573-348-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
A29423Medicare UPIN
1125Medicare ID - Type UnspecifiedNON PARTICIPANT