Healthcare Provider Details

I. General information

NPI: 1053757526
Provider Name (Legal Business Name): LAKELAND REGIONAL HEALTH SYSTEMS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E CENTRAL AVE
WINTER HAVEN FL
33880-3050
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD MANAGED CARE DEPT
LAKELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-6850
  • Fax: 863-284-6853
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: LANCE GREEN
Title or Position: VP, CFO
Credential:
Phone: 863-687-1100