Provider Demographics
NPI:1598065153
Name:LAKE DRIVE MEDICAL, LLC
Entity Type:Organization
Organization Name:LAKE DRIVE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, JUPITER PROFESSIONAL DEV
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-748-2889
Mailing Address - Street 1:5220 HOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-8910
Mailing Address - Country:US
Mailing Address - Phone:561-748-2889
Mailing Address - Fax:561-748-1523
Practice Address - Street 1:2675 LAKE DR
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-3813
Practice Address - Country:US
Practice Address - Phone:561-748-2889
Practice Address - Fax:561-748-1523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58389Medicare UPIN