Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 18764 | PR |
NPI | 1023422425 |
---|---|
Provider Name | Jorge L. Lacen |
First Address | Homestead, FL 33032-8001 |
Second Address | Lakeland, FL 33805-4723 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2014 |
Last Update Date | 19/03/2018 |