MEDICARE: LAKE EMERGENCY MEDICAL SERVICES, 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	3416L0300X	Land Ambulance	ALS3503	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	:	1497034318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE EMERGENCY MEDICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	2761 WEST OLD HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757
Country	:	US
Telephone Number	:	352-383-4554
Fax Number	:	352-385-9063

Provider Business Practice Location Address
First Line	:	2761 WEST OLD HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757
Country	:	US
Telephone Number	:	352-383-4554
Fax Number	:	352-385-9063

Authorized Official
Title or Position	:	BOARD CHAIRMAN
Name	:	MR. WELTON G. CADWELL
Credential	:
Telephone Number	:	352-343-9850

Provider Enumeration Date	:	08/09/2011
Last Update Date	:	01/18/2012

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