Healthcare Provider Details

I. General information

NPI: 1700800406
Provider Name (Legal Business Name): LSR ADVANCED MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7612 BAY PKWY SUITE B
BROOKLYN NY
11214-1516
US

IV. Provider business mailing address

7612 BAY PKWY SUITE B
BROOKLYN NY
11214-1516
US

V. Phone/Fax

Practice location:
  • Phone: 718-368-2200
  • Fax: 718-368-0400
Mailing address:
  • Phone: 718-368-2200
  • Fax: 718-368-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: LARISA REPNINA
Title or Position: MANAGER
Credential:
Phone: 718-368-2200