Provider Demographics
NPI:1285040097
Name:LAKE CITY BIRTH, LLC
Entity type:Organization
Organization Name:LAKE CITY BIRTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:386-288-0698
Mailing Address - Street 1:5113 256TH ST
Mailing Address - Street 2:
Mailing Address - City:O BRIEN
Mailing Address - State:FL
Mailing Address - Zip Code:32071-4435
Mailing Address - Country:US
Mailing Address - Phone:386-299-0698
Mailing Address - Fax:800-853-5087
Practice Address - Street 1:5113 256TH ST
Practice Address - Street 2:
Practice Address - City:O BRIEN
Practice Address - State:FL
Practice Address - Zip Code:32071-4435
Practice Address - Country:US
Practice Address - Phone:386-299-0698
Practice Address - Fax:800-853-5087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW 294261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing