Provider Demographics
NPI:1902280167
Name:LAKE AUDIOLOGY & HEARING CENTER LLC
Entity type:Organization
Organization Name:LAKE AUDIOLOGY & HEARING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:352-729-0848
Mailing Address - Street 1:17521 US HIGHWAY 441 STE 9
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6737
Mailing Address - Country:US
Mailing Address - Phone:352-729-0848
Mailing Address - Fax:
Practice Address - Street 1:17521 US HIGHWAY 441 STE 9
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6737
Practice Address - Country:US
Practice Address - Phone:352-729-0849
Practice Address - Fax:352-354-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1457231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ698XMedicare UPIN