Provider Demographics
NPI:1023347648
Name:FLOWER OF THE LAKE FAMILY PRACTICE PA
Entity type:Organization
Organization Name:FLOWER OF THE LAKE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-357-7200
Mailing Address - Street 1:720 N BAY ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2964
Mailing Address - Country:US
Mailing Address - Phone:352-357-7200
Mailing Address - Fax:352-357-7100
Practice Address - Street 1:720 N BAY ST
Practice Address - Street 2:SUITE 5
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2964
Practice Address - Country:US
Practice Address - Phone:352-357-7200
Practice Address - Fax:352-357-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6731261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF22880Medicare UPIN