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General NPI Number Information
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NPI Number | 1871582296
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Entity Type | Organization
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Legal Business Name | LAKE BUTLER MEDICAL CLINIC INC
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Dates
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Enumeration Date | 10/18/2005
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Last Update Date | 06/29/2010
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Provider Practice Location Address
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Address Line | 675 E MAIN ST
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City | LAKE BUTLER
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State | FL
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Zip | 32054-1352
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Country | US
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Telephone | 386-496-1328
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Fax | 386-496-2227
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Provider Business Mailing Address
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Address Line | PO BOX 188
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City | LAKE BUTLER
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State | FL
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Zip | 32054-0188
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Country | US
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Telephone | 386-496-1328
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Fax | 386-496-2227
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MARTHA REGINA LLOYD
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Credential | MD
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Telephone | 386-496-1328
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ME81421
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License Number State | FL
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