Healthcare Provider Details

I. General information

NPI: 1306467790
Provider Name (Legal Business Name): LUBOMYR LAZOR MUTIS SA-C, IMG.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5963 CHURCHILL SQUARE WAY
GROVELAND FL
34736-3128
US

IV. Provider business mailing address

5963 CHURCHILL SQUARE WAY
GROVELAND FL
34736-3128
US

V. Phone/Fax

Practice location:
  • Phone: 407-927-0778
  • Fax:
Mailing address:
  • Phone: 407-927-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19543
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: