Provider Demographics
NPI:1700252079
Name:LAUDERDALE LAKES MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:LAUDERDALE LAKES MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-484-6440
Mailing Address - Street 1:3296 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5615
Mailing Address - Country:US
Mailing Address - Phone:954-484-6440
Mailing Address - Fax:954-909-5381
Practice Address - Street 1:3296 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5615
Practice Address - Country:US
Practice Address - Phone:954-484-6440
Practice Address - Fax:954-909-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty