Organization
LAKESHORE PEDIATRICS PC
Active
Organization
LAKESHORE PEDIATRICS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AGUSTIN RIVAS MD (OWNER)
(256) 386-4151
Entity
Organization
Contact information
Practice address
12521 AL HIGHWAY 157 STE B, MOULTON, AL 35650-1937
(256) 974-6300
Mailing address
1120 S JACKSON HWY STE 304, SHEFFIELD, AL 35660-5773
(256) 386-4151
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
17108
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1588002455
—
AL
Enumeration date
07/22/2013
Last updated
07/22/2013
Update your record
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