Provider Demographics
NPI:1053582627
Name:LAKEVIEW FAMILY HEALTH CARE
Entity type:Organization
Organization Name:LAKEVIEW FAMILY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-854-1800
Mailing Address - Street 1:2090 SMOKETREE AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5806
Mailing Address - Country:US
Mailing Address - Phone:928-854-1800
Mailing Address - Fax:928-854-1818
Practice Address - Street 1:2090 SMOKETREE AVE N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5806
Practice Address - Country:US
Practice Address - Phone:928-854-1800
Practice Address - Fax:928-854-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCG1872OtherRAILROAD MEDICARE
AZG96720OtherMEDICARE GROUP
AZAZ0857940OtherBLUE CROSS BLUE SHIELD AZ
AZ470724Medicaid
AZAZ0857940OtherBLUE CROSS BLUE SHIELD AZ
AZG96720OtherMEDICARE GROUP