Provider Demographics
NPI:1104072594
Name:PRIMECARE AT TWIN LAKES LLC
Entity type:Organization
Organization Name:PRIMECARE AT TWIN LAKES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-274-2212
Mailing Address - Street 1:1890 LPGA BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7130
Mailing Address - Country:US
Mailing Address - Phone:386-274-2212
Mailing Address - Fax:386-274-1508
Practice Address - Street 1:1327 SAXON DR
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-3160
Practice Address - Country:US
Practice Address - Phone:386-767-2402
Practice Address - Fax:386-767-1566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10698261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5814Medicare PIN