Healthcare Provider Details

I. General information

NPI: 1578922613
Provider Name (Legal Business Name): LAKE CITY INSTITUTE OF NEUROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

IV. Provider business mailing address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

V. Phone/Fax

Practice location:
  • Phone: 407-818-1664
  • Fax: 407-818-1654
Mailing address:
  • Phone: 407-818-1664
  • Fax: 407-818-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. REKHA NIDADAVOLU
Title or Position: MANAGER
Credential:
Phone: 305-905-9316