Provider Demographics
NPI:1336196278
Name:LAKE WALES MEDICAL WALK IN CLINIC PA
Entity Type:Organization
Organization Name:LAKE WALES MEDICAL WALK IN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-676-6007
Mailing Address - Street 1:1611 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4309
Mailing Address - Country:US
Mailing Address - Phone:863-676-6007
Mailing Address - Fax:863-676-7659
Practice Address - Street 1:1611 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4309
Practice Address - Country:US
Practice Address - Phone:863-676-6007
Practice Address - Fax:863-676-7659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265413000Medicaid
FL97246OtherBLUE CROSS BLUE SHEILD FL
159572100OtherDEPARTMENT OF LABOR OWCP
000005600OtherHUMANA
3499276OtherAETNA HEALTH MGMT LLC
========= 0014OtherCIGNA HEALTH CARE
159572100OtherDEPARTMENT OF LABOR OWCP
3499276OtherAETNA HEALTH MGMT LLC
FL97246OtherBLUE CROSS BLUE SHEILD FL