Provider Demographics
NPI:1366521395
Name:LAKE MEDICAL CENTER
Entity type:Organization
Organization Name:LAKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-453-7331
Mailing Address - Street 1:1201 SILOAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-2811
Mailing Address - Country:US
Mailing Address - Phone:706-453-7331
Mailing Address - Fax:706-453-2812
Practice Address - Street 1:1201 SILOAM RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-2811
Practice Address - Country:US
Practice Address - Phone:706-453-7331
Practice Address - Fax:706-453-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health