Healthcare Provider Details

I. General information

NPI: 1023347648
Provider Name (Legal Business Name): FLOWER OF THE LAKE FAMILY PRACTICE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N BAY ST SUITE 5
EUSTIS FL
32726-2964
US

IV. Provider business mailing address

720 N BAY ST SUITE 5
EUSTIS FL
32726-2964
US

V. Phone/Fax

Practice location:
  • Phone: 352-357-7200
  • Fax: 352-357-7100
Mailing address:
  • Phone: 352-357-7200
  • Fax: 352-357-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberOS6731
License Number StateFL

VIII. Authorized Official

Name: MS. MARGARET HAYDEN
Title or Position: PRESIDENT
Credential: DO
Phone: 352-357-7200