Provider Demographics
NPI:1639247034
Name:LAKE, ROSS (ROSS LAKE)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:LAKE
Suffix:
Gender:M
Credentials:ROSS LAKE
Other - Prefix:
Other - First Name:ROSS
Other - Middle Name:
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:311 LUCE AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5667
Mailing Address - Country:US
Mailing Address - Phone:707-462-4448
Mailing Address - Fax:707-595-5565
Practice Address - Street 1:311 LUCE AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5667
Practice Address - Country:US
Practice Address - Phone:707-462-4448
Practice Address - Fax:707-595-5565
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2909171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist