Healthcare Provider Details

I. General information

NPI: 1194763557
Provider Name (Legal Business Name): LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5406 HOOVER BLVD
TAMPA FL
33634-5330
US

IV. Provider business mailing address

5406 HOOVER BLVD
TAMPA FL
33634-5330
US

V. Phone/Fax

Practice location:
  • Phone: 813-248-8149
  • Fax: 813-884-7085
Mailing address:
  • Phone: 813-248-8149
  • Fax: 813-884-7085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDRA L. DRIVER
Title or Position: VP OF OPERATIONS
Credential: RN
Phone: 727-532-7647