Provider Demographics
NPI:1437104395
Name:LAKE COUNTY HEARING CLINIC INC
Entity Type:Organization
Organization Name:LAKE COUNTY HEARING CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:352-343-4488
Mailing Address - Street 1:3210 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5243
Mailing Address - Country:US
Mailing Address - Phone:352-343-4488
Mailing Address - Fax:352-343-7722
Practice Address - Street 1:3210 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5243
Practice Address - Country:US
Practice Address - Phone:352-343-4488
Practice Address - Fax:352-343-7722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2864Medicare ID - Type UnspecifiedMEDICARE PROVIDER #