Provider Demographics
NPI:1912410804
Name:LAKE SHORE HMA, LLC
Entity Type:Organization
Organization Name:LAKE SHORE HMA, LLC
Other - Org Name:SHANDS LAKE SHORE REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/ DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-925-4565
Mailing Address - Street 1:368 NE FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3088
Mailing Address - Country:US
Mailing Address - Phone:386-292-8000
Mailing Address - Fax:386-795-8369
Practice Address - Street 1:368 NE FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3088
Practice Address - Country:US
Practice Address - Phone:386-292-8000
Practice Address - Fax:386-795-8369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE SHORE HMA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4268275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit