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General NPI Number Information
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NPI Number | 1366647802
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Entity Type | Organization
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Legal Business Name | LAKE CENTER OF H.O.P.E., PA
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Dates
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Enumeration Date | 06/15/2007
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Last Update Date | 10/21/2013
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Provider Practice Location Address
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Address Line | 33057 PROFESSIONAL DRIVE SUITE 102
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City | LEESBURG
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State | FL
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Zip | 34788
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Country | US
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Telephone | 352-787-0081
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Fax | 352-314-9444
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Provider Business Mailing Address
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Address Line | 33057 PROFESSIONAL DRIVE SUITE 102
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City | LEESBURG
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State | FL
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Zip | 34788-7507
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Country | US
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Telephone | 352-787-0081
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Fax | 352-314-9444
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Authorized Official
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Title or Position | SECRETARY TREASURER
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Name | MRS. LOURDES NICOLAS UNGSON
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Credential | OFFICE MANAGER
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Telephone | 352-787-0081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 75000006578
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License Number State | FL
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