Provider Demographics
NPI:1578228375
Name:LA LAKERS
Entity type:Organization
Organization Name:LA LAKERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OSTEOPATHIC MEDICINE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:DO ONA CNA APN
Authorized Official - Phone:352-792-8069
Mailing Address - Street 1:PO BOX 5393
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32627-5393
Mailing Address - Country:US
Mailing Address - Phone:352-792-8069
Mailing Address - Fax:
Practice Address - Street 1:2101 NE 2ND ST APT 114
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-8626
Practice Address - Country:US
Practice Address - Phone:352-792-8069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No174200000XOther Service ProvidersMeals
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No333600000XSuppliersPharmacy
No385H00000XRespite Care FacilityRespite Care