| Organization Name: | COUNTY OF LAKE |
| NPI Number: | 1104124395 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KRISTY KELLY (DEPARTMENT HEAD) |
| Mailing Address: | 15850 Dam Road Ext Clearlake |
| State: | CA US |
| Postal Code: | 954229359 |
| Phone Number: | 7079946494 |
| Fax Number: | 7079947164 |
| NPI Enumeration Date: | 03/11/2011 |
| NPI Last Update Date: | 03/11/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR0405X |
| License Number: | 170002BN |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rehabilitation, Substance Use Disorder |
| Taxonomy Definition: | |