Provider Demographics
NPI:1205802048
Name:LAKE RESPIRATORY SERVICES, INC.
Entity type:Organization
Organization Name:LAKE RESPIRATORY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:365-589-5777
Mailing Address - Street 1:1321 S BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5550
Mailing Address - Country:US
Mailing Address - Phone:365-589-5777
Mailing Address - Fax:365-589-4355
Practice Address - Street 1:1321 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5550
Practice Address - Country:US
Practice Address - Phone:365-589-5777
Practice Address - Fax:365-589-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL853332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022293300Medicaid
3859520001Medicare ID - Type Unspecified
1205802048Medicare NSC