Provider Demographics
NPI:1871693564
Name:LAKE MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:LAKE MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:503-635-5044
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-0042
Mailing Address - Country:US
Mailing Address - Phone:503-635-5044
Mailing Address - Fax:503-635-3255
Practice Address - Street 1:550 3RD ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3002
Practice Address - Country:US
Practice Address - Phone:503-635-5044
Practice Address - Fax:503-635-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12913261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty