Provider Demographics
NPI:1912570045
Name:LAKE MEDICAL IMAGING AND BREAST CENTER AT THE VILLAGES LLC
Entity Type:Organization
Organization Name:LAKE MEDICAL IMAGING AND BREAST CENTER AT THE VILLAGES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:365-352-2583
Mailing Address - Street 1:734 N 3RD ST STE 115
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5287
Mailing Address - Country:US
Mailing Address - Phone:352-365-2583
Mailing Address - Fax:352-728-6749
Practice Address - Street 1:910 OLD CAMP RD STE 120
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5605
Practice Address - Country:US
Practice Address - Phone:352-787-5858
Practice Address - Fax:352-787-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101183204Medicaid