Provider Demographics
NPI:1639636897
Name:INFECTIOUS DISEASE OF LAKE COUNTY,LLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE OF LAKE COUNTY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YULISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASTUDILLO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:352-835-2391
Mailing Address - Street 1:2050 CLASSIQUE LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 CLASSIQUE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5787
Practice Address - Country:US
Practice Address - Phone:352-835-2391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty