Provider Demographics
NPI:1497034318
Name:LAKE EMERGENCY MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:LAKE EMERGENCY MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WELTON
Authorized Official - Middle Name:G
Authorized Official - Last Name:CADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-343-9850
Mailing Address - Street 1:2761 WEST OLD HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:352-383-4554
Mailing Address - Fax:352-385-9063
Practice Address - Street 1:2761 WEST OLD HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-383-4554
Practice Address - Fax:352-385-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALS35033416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004071400Medicaid
FLFP018AMedicare PIN