Provider Demographics
NPI:1851364285
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:CMS LAKELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-396-9798
Mailing Address - Street 1:4718 OLD HIGHWAY 37 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:863-701-1151
Mailing Address - Fax:863-701-1165
Practice Address - Street 1:4718 OLD HIGHWAY 37 SOUTH
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813
Practice Address - Country:US
Practice Address - Phone:863-701-1151
Practice Address - Fax:863-701-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052553700Medicaid