Healthcare Provider Details

I. General information

NPI: 1023731239
Provider Name (Legal Business Name): FLORIDA LAKES ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 LAKEVIEW DR
SEBRING FL
33870-2005
US

IV. Provider business mailing address

4759 LAKEVIEW DR
SEBRING FL
33870-2005
US

V. Phone/Fax

Practice location:
  • Phone: 863-402-5600
  • Fax: 863-402-5602
Mailing address:
  • Phone: 863-402-5600
  • Fax: 863-402-5602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS LACKEY II
Title or Position: OWNER
Credential: DO
Phone: 863-402-5600