Provider Demographics
NPI:1992216568
Name:ELITE MEDICAL SERVICES AT LAKESIDE LLC
Entity Type:Organization
Organization Name:ELITE MEDICAL SERVICES AT LAKESIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHEPPKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-436-2291
Mailing Address - Street 1:PO BOX 12010
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-2010
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:LAKESIDE MEDICAL CENTER EMERGENCY DEPARTMENT
Practice Address - Street 2:39200 HOOKER HWY
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-5368
Practice Address - Country:US
Practice Address - Phone:561-996-6571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty