| Organization Name: | LAKE GIRL, INC |
| NPI Number: | 1255730446 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RENEE L WILLER (OWNER) |
| Mailing Address: | 4581 Gravois Rd House Springs |
| State: | MO US |
| Postal Code: | 630511374 |
| Phone Number: | 6366719980 |
| Fax Number: | 6366719981 |
| NPI Enumeration Date: | 08/14/2014 |
| NPI Last Update Date: | 12/09/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 138512 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |