=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356088512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKES ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2022
-----------------------------------------------------
Last Update Date | 05/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 W 76TH ST STE 101
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-403-2560
-----------------------------------------------------
Fax | 786-439-2282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 W 76TH ST STE 101
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-5505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-403-2560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DAMARYS VEGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-403-2560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------