# LAKE MEDICAL GROUP, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215767496
- **Authorized official:** ALFONSO GONZALEZ (PRESIDENT)
- **Authorized official phone:** (305) 507-4400

## Contact information

- **Practice address:** 14750 NW 77TH CT STE 304, MIAMI LAKES, FL 33016-1537
- **Practice address phone:** (305) 507-4400
- **Practice address fax:** (305) 826-2840
- **Mailing address:** 14750 NW 77TH CT STE 304, MIAMI LAKES, FL 33016-1537
- **Mailing address phone:** (305) 507-4400
- **Mailing address fax:** (305) 826-2840

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 171M00000X | Case Manager/Care Coordinator | — | NULL | — |
| 171M00000X | Case Manager/Care Coordinator | — | — | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | — |
| 208VP0000X | Pain Medicine Physician | — | NULL | — |
| 208VP0000X | Pain Medicine Physician | — | — | — |
| 261QA0600X | Adult Day Care Clinic/Center | — | NULL | — |
| 261QI0500X | Infusion Therapy Clinic/Center | — | NULL | — |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | Yes |
| 261QR0401X | Comprehensive Outpatient Rehabilitation Facility (CORF) | — | NULL | — |
| 261QX0100X | Occupational Medicine Clinic/Center | — | NULL | — |
| 291U00000X | Clinical Medical Laboratory | — | NULL | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 335V00000X | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier | — | NULL | — |

## Other

- **Enumeration date:** 08/03/2024
- **Last updated:** 08/03/2024