Katrina Lake MD LLC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

Legal business name

KATRINA LAKE MD LLC

Doing business as

Live. Love. Wellness MD

Practice address

18503 Bellamy Rd
Country Club Hills, IL 60478-5279

Phone

(708) 365-8343

NPI assigned

Apr 14, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Katrina Lake, MD

Title

Owner

Phone

(708) 308-8974

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Live. Love. Wellness MD Doing business as

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1586822400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1588291200000",
    "number": "1013536663",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18503 BELLAMY RD",
            "city": "COUNTRY CLUB HILLS",
            "state": "IL",
            "postal_code": "604785279"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18503 BELLAMY RD",
            "city": "COUNTRY CLUB HILLS",
            "state": "IL",
            "postal_code": "604785279",
            "telephone_number": "708-365-8343"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4053 183rd St Unit 2326",
            "address_purpose": "LOCATION",
            "city": "Country Club Hills",
            "state": "IL",
            "postal_code": "604783413",
            "country_code": "US",
            "telephone_number": "708-365-8343",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "KATRINA LAKE MD LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-04-14",
        "last_updated": "2020-05-01",
        "certification_date": "2020-05-01",
        "status": "A",
        "authorized_official_last_name": "LAKE",
        "authorized_official_first_name": "KATRINA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "708-308-8974",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036141229",
            "state": "IL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "klakemd@livelovewellnessmd.com",
            "affiliation": "N",
            "address_1": "4053 183rd St Unit 2326",
            "city": "Country Club Hills",
            "state": "IL",
            "country_code": "US",
            "postal_code": "604783413",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Live. Love. Wellness MD",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Live. Love. Wellness MD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Multi-Specialty Clinic/Center in Country Club Hills, IL
• Providers in Country Club Hills, IL by specialty
• Multi-Specialty Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.