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FAMILY PRACTICE BY THE LAKE, LLC

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Company Details

Name: FAMILY PRACTICE BY THE LAKE, LLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 04 Apr 2018 (7 years ago)
Financial Date End: 30 Apr 2026
Entity Number: 602768
Place of Formation: IDAHO
File Number: 602768
ZIP code: 83814
County: Kootenai County
Principal Address: 1875 N LAKEWOOD DR STE 205 COEUR D ALENE, ID 83814
Mailing Address: JACQUELINE WAGNER STE 205 1875 N LAKEWOOD DR COEUR D ALENE, ID 83814-4928

Agent

Name Role Address
JACQUELINE WAGNER Agent 1875 N LAKEWOOD DR., 205, JACQUELINE WAGNER, ARNP, COEUR D ALENE, ID 83814

Member

Name Role Address Appointed On
JACQUELINE WAGNER Member 1875 N LAKEWOOD DR, COEUR D ALENE, ID 83814 2020-07-09

National Provider Identifier

NPI Number:
1295283810
Certification Date:
2024-03-25

Authorized Person:

Name:
JACQUELINE LEE WAGNER
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
363L00000X - Nurse Practitioner
Is Primary:
No
Selected Taxonomy:
207Q00000X - Family Medicine Physician
Is Primary:
Yes

Contacts:

Fax:
2089664031

Filing

Filing Name Filing Number Filing date
Annual Report 0006132778 2025-03-01
Annual Report 0005697769 2024-04-19
Annual Report 0005217008 2023-05-02
Annual Report 0004650599 2022-03-09
Annual Report 0004237401 2021-04-06

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Date of last update: 05 Jul 2025

Sources: Idaho Secretary of State