Provider Demographics
NPI:1871582296
Name:LAKE BUTLER MEDICAL CLINIC INC
Entity type:Organization
Organization Name:LAKE BUTLER MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-496-1328
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-0188
Mailing Address - Country:US
Mailing Address - Phone:386-496-1328
Mailing Address - Fax:386-496-2227
Practice Address - Street 1:675 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1352
Practice Address - Country:US
Practice Address - Phone:386-496-1328
Practice Address - Fax:386-496-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81421261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266578600Medicaid
FL266578600Medicaid
FLAK946Medicare PIN