Organization
LAKE NEUROLOGY CLINIC, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARILYN C GLOVER (OFFICE MANAGER)
(352) 360-1122
Entity
Organization
Contact information
Practice address
608 S 9TH STREET, STE A, LEESBURG, FL 34748
(352) 360-1122
(352) 360-1123
Mailing address
PO BOX 490123, LEESBURG, FL 34749-0123
(352) 360-1122
(352) 360-1123
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
ME76490
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
130025175
MEDICARE RAILROAD
FL
05
—
257303200
—
FL
01
—
44751
BCBS
FL
Enumeration date
11/15/2006
Last updated
03/05/2010
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