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General NPI Number Information
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NPI Number | 1477982171
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Entity Type | Organization
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Legal Business Name | LAKE SHORE CENTER FOR AESTHETICS & PLASTIC SURGERY PA
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Dates
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Enumeration Date | 11/04/2013
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Last Update Date | 01/07/2014
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Provider Practice Location Address
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Address Line | 263 SW PROFESSIONAL GLN
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City | LAKE CITY
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State | FL
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Zip | 32025-1105
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Country | US
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Telephone | 386-755-6676
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Fax | 386-755-1667
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Provider Business Mailing Address
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Address Line | 263 SW PROFESSIONAL GLN
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City | LAKE CITY
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State | FL
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Zip | 32025-1105
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Country | US
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Telephone | 386-755-6676
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Fax | 386-755-1667
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Authorized Official
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Title or Position | PRESIDENT
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Name | MELINDA KEENER
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Credential | MD
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Telephone | 386-755-6676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | ME 105501
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License Number State | FL
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