Healthcare Provider Details

I. General information

NPI: 1104829316
Provider Name (Legal Business Name): LAKE HEALTH CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 MOUNT HOMER RD
EUSTIS FL
32726-6258
US

IV. Provider business mailing address

910 MOUNT HOMER RD
EUSTIS FL
32726-6258
US

V. Phone/Fax

Practice location:
  • Phone: 352-357-8615
  • Fax:
Mailing address:
  • Phone: 352-357-8615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberNOTREQUIRED
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNOTREQUIRED
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberNOTREQUIRED
License Number StateFL

VIII. Authorized Official

Name: LORRI J HARTLEY
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 352-357-8615