1700958600 NPI number — LAKE NEUROLOGY CLINIC, P.A.

Table of content: (NPI 1700958600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700958600 NPI number — LAKE NEUROLOGY CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE NEUROLOGY CLINIC, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700958600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 490123
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34749-0123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-360-1122
Provider Business Mailing Address Fax Number:
352-360-1123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 S 9TH STREET
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-360-1122
Provider Business Practice Location Address Fax Number:
352-360-1123
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLOVER
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
352-360-1122

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME76490 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130025175 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 44751 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 257303200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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