Healthcare Provider Details

I. General information

NPI: 1770843187
Provider Name (Legal Business Name): LAKE MACACO INPATIENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1796 US HIGHWAY 441 N
OKEECHOBEE FL
34972-1918
US

IV. Provider business mailing address

PO BOX 37878
PHILADELPHIA PA
19101-0178
US

V. Phone/Fax

Practice location:
  • Phone: 863-763-2151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132