Provider Demographics
NPI:1760802912
Name:LAKELAND IMMEDIATE CARE CENTER
Entity type:Organization
Organization Name:LAKELAND IMMEDIATE CARE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-445-3874
Mailing Address - Street 1:1951 OAK ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-3738
Mailing Address - Country:US
Mailing Address - Phone:269-262-4749
Mailing Address - Fax:269-262-4739
Practice Address - Street 1:1951 OAK ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3738
Practice Address - Country:US
Practice Address - Phone:269-262-4749
Practice Address - Fax:269-262-4739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKELAND IMMEDIATE CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-25
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)