Healthcare Provider Details

I. General information

NPI: 1770780272
Provider Name (Legal Business Name): LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 N 50TH ST
TAMPA FL
33619-3104
US

IV. Provider business mailing address

7527 ULMERTON RD
LARGO FL
33771-4548
US

V. Phone/Fax

Practice location:
  • Phone: 813-247-4489
  • Fax: 813-247-4480
Mailing address:
  • Phone: 727-586-0138
  • Fax: 727-586-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SANDRA L. DRIVER
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: R.N.
Phone: 727-532-7647