1770780272 NPI number — LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.

Table of content: (NPI 1770780272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770780272 NPI number — LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770780272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7527 ULMERTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33771-4548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-586-0138
Provider Business Mailing Address Fax Number:
727-586-6954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 N 50TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33619-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-247-4489
Provider Business Practice Location Address Fax Number:
813-247-4480
Provider Enumeration Date:
06/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DRIVER
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
727-532-7647

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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