Provider Demographics
NPI:1366647802
Name:LAKE CENTER OF H.O.P.E., PA
Entity Type:Organization
Organization Name:LAKE CENTER OF H.O.P.E., PA
Other - Org Name:NICK M UNGSON, .M.D., PA
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:NICOLAS
Authorized Official - Last Name:UNGSON
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:352-787-0081
Mailing Address - Street 1:33057 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-7507
Mailing Address - Country:US
Mailing Address - Phone:352-787-0081
Mailing Address - Fax:352-314-9444
Practice Address - Street 1:33057 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788
Practice Address - Country:US
Practice Address - Phone:352-787-0081
Practice Address - Fax:352-314-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75000006578174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4978Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER