Healthcare Provider Details

I. General information

NPI: 1134682263
Provider Name (Legal Business Name): LA LAKERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2019
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 NE 2ND ST
GAINESVILLE FL
32609-8627
US

IV. Provider business mailing address

2101 NE 2ND ST APT 114
GAINESVILLE FL
32609-8626
US

V. Phone/Fax

Practice location:
  • Phone: 352-792-8069
  • Fax:
Mailing address:
  • Phone: 352-792-8069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM SILVER
Title or Position: PRESIDENT OF OPERATIONS
Credential:
Phone: 184-462-2855