MEDICARE: LAKE HEALTH CARE CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	NOTREQUIRED	FL
2	213E00000X	Podiatrist	NOTREQUIRED	FL
3	111N00000X	Chiropractor	NOTREQUIRED	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104829316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HEALTH CARE CENTER INC

Provider Business Mailing Address
First Line	:	910 MOUNT HOMER RD
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-6258
Country	:	US
Telephone Number	:	352-357-8615
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 MOUNT HOMER RD
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-6258
Country	:	US
Telephone Number	:	352-357-8615
Fax Number	:

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	LORRI J HARTLEY
Credential	:
Telephone Number	:	352-357-8615

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/22/2010

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Directions to “LAKE HEALTH CARE CENTER INC ” Practice Location

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