Provider Demographics
NPI:1649244567
Name:LAKELAND FL ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:LAKELAND FL ENDOSCOPY ASC LLC
Other - Org Name:SURGERY CENTER OF LAKELAND HILLS BOULEVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:3340 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-1974
Mailing Address - Country:US
Mailing Address - Phone:863-682-3239
Mailing Address - Fax:863-682-3462
Practice Address - Street 1:3340 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-1974
Practice Address - Country:US
Practice Address - Phone:863-682-3239
Practice Address - Fax:863-682-3462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1230261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00221727OtherRAILROAD MEDICARE
FL075976700Medicaid
FL075976700Medicaid
FL10C0001446Medicare Oscar/Certification
FLF1446Medicare PIN