Provider Demographics
NPI:1922575802
Name:LAKEWOOD CCL, LLC
Entity Type:Organization
Organization Name:LAKEWOOD CCL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-643-9070
Mailing Address - Street 1:5571 E SR 44 STE 501
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-8282
Mailing Address - Country:US
Mailing Address - Phone:352-643-9070
Mailing Address - Fax:352-571-6787
Practice Address - Street 1:5571 E SR 44 STE 501
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-8282
Practice Address - Country:US
Practice Address - Phone:352-643-9070
Practice Address - Fax:352-571-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty