MEDICARE: HEALTHWORKS OF LAKE CITY, 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	174400000X	Specialist	PT17329	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y7572	OTHER	FL	BCBS PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245235183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHWORKS OF LAKE CITY, INC.

Provider Business Mailing Address
First Line	:	1206 SW MAIN BLVD
Second Line	:	STE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-752-1652
Fax Number	:	386-752-0939

Provider Business Practice Location Address
First Line	:	1206 SW MAIN BLVD
Second Line	:	STE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-752-1652
Fax Number	:	386-752-0939

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MICHAEL A BEARDSLEY
Credential	:	PT
Telephone Number	:	386-752-1652

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	01/12/2012

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