Healthcare Provider Details

I. General information

NPI: 1750823886
Provider Name (Legal Business Name): LAKE ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17355 SE 109TH TERRACE RD
SUMMERFIELD FL
34491-8930
US

IV. Provider business mailing address

17355 SE 109TH TERRACE RD
SUMMERFIELD FL
34491
US

V. Phone/Fax

Practice location:
  • Phone: 352-245-0846
  • Fax:
Mailing address:
  • Phone: 352-245-0846
  • Fax: 352-245-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: COLLIN LEMAISTRE
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 404-781-2921