Provider Demographics
NPI:1104199942
Name:LAKEVILLE COMPREHENSIVE MEDICAL INJURY CARE P.L.L.C
Entity Type:Organization
Organization Name:LAKEVILLE COMPREHENSIVE MEDICAL INJURY CARE P.L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAHANSHAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOFEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-358-7557
Mailing Address - Street 1:2035 LAKEVILLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1661
Mailing Address - Country:US
Mailing Address - Phone:516-492-3307
Mailing Address - Fax:516-492-3299
Practice Address - Street 1:2035 LAKEVILLE RD STE 300
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1661
Practice Address - Country:US
Practice Address - Phone:516-492-3307
Practice Address - Fax:516-492-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248529-1208100000X
NY235820208100000X
NYA241419208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty