MEDICARE: LAUDERDALE LAKES MEDICAL 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	207R00000X	Internal Medicine Physician	ME62781	FL

General Provider Information

NPI Number	:	1700252079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUDERDALE LAKES MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	3296 N STATE ROAD 7
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33319-5615
Country	:	US
Telephone Number	:	954-484-6440
Fax Number	:	954-909-5381

Provider Business Practice Location Address
First Line	:	3296 N STATE ROAD 7
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33319-5615
Country	:	US
Telephone Number	:	954-484-6440
Fax Number	:	954-909-5381

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. BASIL MANGRA
Credential	:	M.D.
Telephone Number	:	954-484-6440

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/20/2015

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