Provider Demographics
NPI:1346524956
Name:INNOVATIVE PRIMARY CARE PLC
Entity Type:Organization
Organization Name:INNOVATIVE PRIMARY CARE PLC
Other - Org Name:LAKE PALLIATIVE CARE PROVIDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:AJIT
Authorized Official - Middle Name:VALLABHDAS
Authorized Official - Last Name:HANSALIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-638-6493
Mailing Address - Street 1:901 N GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2805
Mailing Address - Country:US
Mailing Address - Phone:352-508-7040
Mailing Address - Fax:
Practice Address - Street 1:901 N GROVE ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2805
Practice Address - Country:US
Practice Address - Phone:352-508-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH524018710510OtherDRIVER LICENSE