Basic Information
| Provider Information | |||||||||
| NPI: | 1508258906 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND REGIONAL HEALTH SYSTEMS, INC. | ||||||||
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| OtherOrganizationName: | LAKELAND HIGHLANDS CAMPUS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871100 | ||||||||
| FaxNumber: | 8636871473 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 LAKELAND HIGHLANDS RD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636827737 | ||||||||
| FaxNumber: | 8636820761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 8636871100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.