MEDICARE: LAKE PARK GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency		AZ
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1578756334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE PARK GROUP, LLC

Provider Business Mailing Address
First Line	:	2114 W GRANT RD
Second Line	:	24
City	:	TUCSON
State	:	AZ
Zip	:	85745-1141
Country	:	US
Telephone Number	:	520-365-2025
Fax Number	:	520-365-2027

Provider Business Practice Location Address
First Line	:	2114 W GRANT RD
Second Line	:	24
City	:	TUCSON
State	:	AZ
Zip	:	85745-1141
Country	:	US
Telephone Number	:	520-365-2025
Fax Number	:	520-365-2027

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MIRIAM COSEY
Credential	:
Telephone Number	:	520-262-5583

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	03/14/2014

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