Provider Demographics
NPI:1457425159
Name:LAKESHORE TUBAL REVERSAL CENTER
Entity Type:Organization
Organization Name:LAKESHORE TUBAL REVERSAL CENTER
Other - Org Name:LAKESHORE SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:ASHLEIGH
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-531-1181
Mailing Address - Street 1:2320 LIMESTONE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:877-588-5594
Mailing Address - Fax:770-531-0053
Practice Address - Street 1:2320 LIMESTONE PARKWAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:877-588-5594
Practice Address - Fax:770-531-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA LIC 022231261QA1903X
GADEA AG5691452261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
E53967Medicare UPIN