MEDICARE: LQV LAUDERDALE BEACH 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1891269239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LQV LAUDERDALE BEACH LLC

Provider Business Mailing Address
First Line	:	PO BOX 670902
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-0016
Country	:	US
Telephone Number	:	954-579-4305
Fax Number	:	209-830-4696

Provider Business Practice Location Address
First Line	:	3349 NE 33RD ST STE B
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7111
Country	:	US
Telephone Number	:	954-909-4998
Fax Number	:	209-830-4696

Authorized Official
Title or Position	:	OWNER
Name	:	SAM TEJADA
Credential	:
Telephone Number	:	954-579-4305

Provider Enumeration Date	:	01/18/2019
Last Update Date	:	01/18/2019

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