Provider Demographics
NPI:1033651971
Name:LAKE FAMILY PRACTICE
Entity Type:Organization
Organization Name:LAKE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-242-4816
Mailing Address - Street 1:1317 N PINE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-4833
Mailing Address - Country:US
Mailing Address - Phone:407-532-4615
Mailing Address - Fax:407-286-2985
Practice Address - Street 1:1317 N PINE HILLS RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-4833
Practice Address - Country:US
Practice Address - Phone:407-532-4615
Practice Address - Fax:407-286-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty