Healthcare Provider Details

I. General information

NPI: 1174727937
Provider Name (Legal Business Name): FLORIDA LAKES SURGICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4751 LAKEVIEW DR
SEBRING FL
33870-2064
US

IV. Provider business mailing address

4751 LAKEVIEW DR
SEBRING FL
33870-2064
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 Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS C LACKEY II
Title or Position: OWNER
Credential: DO
Phone: 86340265600