Provider Demographics
NPI:1073576146
Name:MEDICAL VENTURES OF AMERICA
Entity Type:Organization
Organization Name:MEDICAL VENTURES OF AMERICA
Other - Org Name:LAKE REGIONAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-315-8881
Mailing Address - Street 1:8404 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-4016
Mailing Address - Country:US
Mailing Address - Phone:352-315-1651
Mailing Address - Fax:
Practice Address - Street 1:8404 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-4016
Practice Address - Country:US
Practice Address - Phone:352-315-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266435600Medicaid
FL10D1004910OtherMEDICARE CLIA #
FL34537OtherBLUE GRP PROV #
FLB902BOtherBLUE SHIELD FACILITY #
FL34537OtherBLUE GRP PROV #
FL34537Medicare ID - Type UnspecifiedMEDICARE GROUP PROV #