Provider Demographics
NPI:1477982171
Name:LAKE SHORE CENTER FOR AESTHETICS & PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:LAKE SHORE CENTER FOR AESTHETICS & PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-6676
Mailing Address - Street 1:263 SW PROFESSIONAL GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1105
Mailing Address - Country:US
Mailing Address - Phone:386-755-6676
Mailing Address - Fax:386-755-1667
Practice Address - Street 1:263 SW PROFESSIONAL GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1105
Practice Address - Country:US
Practice Address - Phone:386-755-6676
Practice Address - Fax:386-755-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 105501208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty