Provider Demographics
NPI:1063055820
Name:LAGO MAR MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:LAGO MAR MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OPABUNMI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:409-515-3915
Mailing Address - Street 1:8030 FM 1765 STE C-102
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-3689
Mailing Address - Country:US
Mailing Address - Phone:409-515-3915
Mailing Address - Fax:409-299-3773
Practice Address - Street 1:8030 FM 1765 STE C-102
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-3689
Practice Address - Country:US
Practice Address - Phone:409-515-3915
Practice Address - Fax:409-299-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty