Angus Lake Infusion Services

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

License

PHHH000055 Issued in GA

Legal business name

ANGUS LAKE INFUSION SERVICES

Doing business as

Angus Lake Vital Care

Practice address

240 Milledgeville Rd
Suite B
Gordon, GA 31031-3827

Phone

(478) 387-2399

Fax

(478) 628-2263

NPI assigned

Apr 8, 2013

Last updated

Oct 18, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Carl Lake Stanley Jr., RPH

Title

Member

Phone

(478) 387-2399

Specialties & licenses 4

Addresses

Other identifiers 1

Other names 1

• Angus Lake Vital Care Doing business as

Locations

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

{
    "created_epoch": "1365379200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1382054400000",
    "number": "1063855211",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 249",
            "city": "GORDON",
            "state": "GA",
            "postal_code": "310310249",
            "telephone_number": "478-387-2399",
            "fax_number": "478-628-2263"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "240 MILLEDGEVILLE RD",
            "address_2": "SUITE B",
            "city": "GORDON",
            "state": "GA",
            "postal_code": "310313827",
            "telephone_number": "478-387-2399",
            "fax_number": "478-628-2263"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ANGUS LAKE INFUSION SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-08",
        "last_updated": "2013-10-18",
        "status": "A",
        "authorized_official_last_name": "STANLEY",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "LAKE",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "478-387-2399",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "GA",
            "license": "PHHH000055",
            "primary": true
        },
        {
            "code": "332BP3500X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Parenteral & Enteral Nutrition",
            "state": "GA",
            "license": "PHHH000055",
            "primary": false
        },
        {
            "code": "3336H0001X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Home Infusion Therapy Pharmacy",
            "state": "GA",
            "license": "PHHH000055",
            "primary": false
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": "GA",
            "license": "PHHH000055",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003137168A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Angus Lake Vital Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Falcon Crest Manor, LLC

• Durable Medical Equipment & Medical Supplies in Gordon, GA
• Providers in Gordon, GA by specialty
• Durable Medical Equipment & Medical Supplies in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2013; 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.