Healthcare Provider Details

I. General information

NPI: 1982572053
Provider Name (Legal Business Name): LAKES HEALTHCARE & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8205 COMMERCE WAY STE 125
MIAMI LAKES FL
33016-1668
US

IV. Provider business mailing address

8205 COMMERCE WAY STE 125
MIAMI LAKES FL
33016-1668
US

V. Phone/Fax

Practice location:
  • Phone: 786-261-9628
  • Fax: 305-827-5545
Mailing address:
  • Phone: 786-261-9628
  • Fax: 305-827-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083T0002X
TaxonomyMedical Toxicology (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. SAMANTHA BOUZA
Title or Position: CEO
Credential: CEO
Phone: 786-261-9628