Healthcare Provider Details

I. General information

NPI: 1801069224
Provider Name (Legal Business Name): LAKESIDE MEDICAL AND AESTHETIC CENTRE LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N HIATUS RD SUITE 203
PEMBROKE PINES FL
33026-5207
US

IV. Provider business mailing address

600 N HIATUS RD SUITE 203
PEMBROKE PINES FL
33026-5207
US

V. Phone/Fax

Practice location:
  • Phone: 954-392-7157
  • Fax: 954-443-4941
Mailing address:
  • Phone: 954-392-7157
  • Fax: 954-443-4941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7420
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME70790
License Number StateFL

VIII. Authorized Official

Name: LYDIA FUXA
Title or Position: ADMINSTRATOR
Credential:
Phone: 954-392-7157