Basic Information
| Provider Information | |||||||||
| NPI: | 1598065153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE DRIVE MEDICAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 HOOD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334188910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617482889 | ||||||||
| FaxNumber: | 5617481523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 LAKE DR | ||||||||
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| City: | RIVIERA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334043813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617482889 | ||||||||
| FaxNumber: | 5617481523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2010 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | BARLOW | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, JUPITER PROFESSIONAL DEV | ||||||||
| AuthorizedOfficialTelephone: | 5617482889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.