Provider Demographics
NPI:1598965634
Name:LAKE CITY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:LAKE CITY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DERENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMBERLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:386-487-3930
Mailing Address - Street 1:208 SW PROSPERITY PLACE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024
Mailing Address - Country:US
Mailing Address - Phone:386-487-3930
Mailing Address - Fax:386-487-3935
Practice Address - Street 1:208 SW PROSPERITY PLACE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024
Practice Address - Country:US
Practice Address - Phone:386-487-3930
Practice Address - Fax:386-487-3935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1046261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-C0001276OtherASC MEDICARE IDENTIFICATI
FL10-C0001276OtherASC MEDICARE IDENTIFICATI