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General NPI Number Information
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NPI Number | 1124195573
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Entity Type | Organization
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Legal Business Name | LAKESHORE MEDICAL CARE CENTER, INC
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 12/27/2010
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Provider Practice Location Address
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Address Line | 4616 SAN JUAN AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32210-3228
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Country | US
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Telephone | 904-384-5385
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Fax | 904-388-5838
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Provider Business Mailing Address
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Address Line | 4616 SAN JUAN AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32210-3228
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Country | US
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Telephone | 904-384-5385
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Fax | 904-388-5838
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MISS TRACY TEAGLE
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Credential |
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Telephone | 904-384-5385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | ME0018387
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 0042816
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License Number State | FL
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