Provider Demographics
NPI:1518340124
Name:MED LAKE CENTER LLC
Entity Type:Organization
Organization Name:MED LAKE CENTER LLC
Other - Org Name:G & I MEDICAL RESEARCH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:ZENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-332-4991
Mailing Address - Street 1:16371 NW 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6044
Mailing Address - Country:US
Mailing Address - Phone:786-332-4991
Mailing Address - Fax:786-409-6203
Practice Address - Street 1:16371 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6044
Practice Address - Country:US
Practice Address - Phone:786-332-4991
Practice Address - Fax:786-409-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC11818208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty