Provider Demographics
NPI:1306015748
Name:LAKE FOOT CLINIC INC
Entity Type:Organization
Organization Name:LAKE FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER OF LAKE FOOT CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROTELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:352-589-1335
Mailing Address - Street 1:629 S GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726
Mailing Address - Country:US
Mailing Address - Phone:352-589-1335
Mailing Address - Fax:352-589-1336
Practice Address - Street 1:629 S GROVE ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726
Practice Address - Country:US
Practice Address - Phone:352-589-1335
Practice Address - Fax:352-589-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1193213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8096OtherMEDICARE GROUP NUMBER
FL5678940001Medicare NSC