Provider Demographics
NPI:1609953587
Name:LAKE COUNTRY AREA AGENCY ON AGING
Entity type:Organization
Organization Name:LAKE COUNTRY AREA AGENCY ON AGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HINZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-447-7661
Mailing Address - Street 1:1105 W DANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-3501
Mailing Address - Country:US
Mailing Address - Phone:434-447-7661
Mailing Address - Fax:434-447-4074
Practice Address - Street 1:1105 W DANVILLE ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-3501
Practice Address - Country:US
Practice Address - Phone:434-447-7661
Practice Address - Fax:434-447-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAADC782951261QA0600X
332B00000X
VAHC0-176683747P1801X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9114629Medicaid