Healthcare Provider Details

I. General information

NPI: 1104298488
Provider Name (Legal Business Name): LAKES HEALTHCARE & SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15700 NW 67TH AVE SUITE 101
MIAMI LAKES FL
33014-2109
US

IV. Provider business mailing address

15700 NW 67TH AVE SUITE 101
MIAMI LAKES FL
33014-2109
US

V. Phone/Fax

Practice location:
  • Phone: 305-698-7074
  • Fax: 305-698-7411
Mailing address:
  • Phone: 305-698-7074
  • Fax: 305-698-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MS. CINDY CLARA MANDULEY-BOUZA
Title or Position: OWNER
Credential:
Phone: 786-261-9628