Provider Demographics
NPI:1366563314
Name:LAKELAND CARE INC
Entity type:Organization
Organization Name:LAKELAND CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-906-5100
Mailing Address - Street 1:N6654 ROLLING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-9471
Mailing Address - Country:US
Mailing Address - Phone:920-906-5100
Mailing Address - Fax:
Practice Address - Street 1:N6654 ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9471
Practice Address - Country:US
Practice Address - Phone:920-906-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69105530Medicaid
WI69005500Medicaid
WI69005530Medicaid
WI69205530Medicaid