Provider Demographics
NPI:1356832190
Name:LAKE SUMPTER ORTHOPEDIC
Entity Type:Organization
Organization Name:LAKE SUMPTER ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEATTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-245-8397
Mailing Address - Street 1:8925 SE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-5312
Mailing Address - Country:US
Mailing Address - Phone:772-245-8397
Mailing Address - Fax:
Practice Address - Street 1:3900 LAKE CENTER DR STE A2
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2203
Practice Address - Country:US
Practice Address - Phone:772-245-8397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center