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General NPI Number Information
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NPI Number | 1700958600
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Entity Type | Organization
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Legal Business Name | LAKE NEUROLOGY CLINIC, P.A.
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 03/05/2010
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Provider Practice Location Address
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Address Line | 608 S 9TH STREET STE A
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City | LEESBURG
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State | FL
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Zip | 34748
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Country | US
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Telephone | 352-360-1122
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Fax | 352-360-1123
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Provider Business Mailing Address
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Address Line | PO BOX 490123
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City | LEESBURG
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State | FL
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Zip | 34749-0123
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Country | US
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Telephone | 352-360-1122
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Fax | 352-360-1123
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARILYN C GLOVER
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Credential |
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Telephone | 352-360-1122
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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 | ME76490
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License Number State | FL
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