Provider Demographics
NPI:1396259735
Name:FREEDOM HEALTH AND WELLNESS OF LAKE CITY, LLC
Entity type:Organization
Organization Name:FREEDOM HEALTH AND WELLNESS OF LAKE CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-623-0850
Mailing Address - Street 1:263 SW PROFESSIONAL GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1105
Mailing Address - Country:US
Mailing Address - Phone:386-623-0850
Mailing Address - Fax:
Practice Address - Street 1:263 SW PROFESSIONAL GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1105
Practice Address - Country:US
Practice Address - Phone:386-623-0850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty