Provider Demographics
NPI:1104829316
Name:LAKE HEALTH CARE CENTER INC
Entity type:Organization
Organization Name:LAKE HEALTH CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-357-8615
Mailing Address - Street 1:910 MOUNT HOMER RD
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6258
Mailing Address - Country:US
Mailing Address - Phone:352-357-8615
Mailing Address - Fax:
Practice Address - Street 1:910 MOUNT HOMER RD
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6258
Practice Address - Country:US
Practice Address - Phone:352-357-8615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNOTREQUIRED207Q00000X, 213E00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396740528Medicare NSC
FL1154560464Medicare NSC
FL1306841119Medicare NSC
1154326981Medicare NSC
FL1982802633Medicare NSC
4772650001Medicare NSC
FL24435Medicare PIN
FL1740285980Medicare NSC
FL1528063757Medicare NSC