Basic Information
| Provider Information | |||||||||
| NPI: | 1154056208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEVIEW TRAUMA AND CRITICAL CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748630 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303748630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 JUDGE TANNER BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704337506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858673800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2022 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | REBOK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP VP/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153725004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.