Provider Demographics
NPI:1750823886
Name:LAKE ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:LAKE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMAISTRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-781-2921
Mailing Address - Street 1:17355 SE 109TH TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491
Mailing Address - Country:US
Mailing Address - Phone:352-245-0846
Mailing Address - Fax:352-245-7768
Practice Address - Street 1:17355 SE 109TH TERRACE RD
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8930
Practice Address - Country:US
Practice Address - Phone:352-245-0846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical