Basic Information
| Provider Information | |||||||||
| NPI: | 1841696762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE WALES HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE WALES MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636761433 | ||||||||
| FaxNumber: | 8636769323 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636761433 | ||||||||
| FaxNumber: | 8636769323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2014 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6159254565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKE WALES HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 4007 | FL | Y | Hospital Units | Psychiatric Unit |
No ID Information.