Provider Demographics
NPI:1619132867
Name:NUTMEG HOLDINGS LLC
Entity Type:Organization
Organization Name:NUTMEG HOLDINGS LLC
Other - Org Name:LAKE BALDWIN MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER / DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:RAFIK
Authorized Official - Last Name:BOUAZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-893-3905
Mailing Address - Street 1:PO BOX 149374
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-9374
Mailing Address - Country:US
Mailing Address - Phone:407-893-3905
Mailing Address - Fax:407-893-3906
Practice Address - Street 1:1459 LAKE BALDWIN LN
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6741
Practice Address - Country:US
Practice Address - Phone:407-893-3905
Practice Address - Fax:407-893-3906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-26
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center