Imperial Boulevard Management,LLC

Primary specialty

DentistTaxonomy code 122300000X

License

1190925 Issued in FL

Legal business name

IMPERIAL BOULEVARD MANAGEMENT,LLC

Practice address

225 Imperial Blvd
Lakeland, FL 33803-4612

Phone

(863) 644-4739

Fax

(863) 644-1333

NPI assigned

Aug 7, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Angel Nichols

Title

Turstee

Phone

(863) 644-4739

Specialties & licenses 1

Addresses

Other names 1

• Lakeland Pediatirc Dental Care Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1218067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218067200000",
    "number": "1851557078",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "225 IMPERIAL BLVD",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338034612",
            "telephone_number": "863-644-4739",
            "fax_number": "863-644-1333"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "225 IMPERIAL BLVD",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338034612",
            "telephone_number": "863-644-4739",
            "fax_number": "863-644-1333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPERIAL BOULEVARD MANAGEMENT,LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-07",
        "last_updated": "2008-08-07",
        "status": "A",
        "authorized_official_last_name": "NICHOLS",
        "authorized_official_first_name": "ANGEL",
        "authorized_official_title_or_position": "TURSTEE",
        "authorized_official_telephone_number": "863-644-4739"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "FL",
            "license": "1190925",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeland Pediatirc Dental Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Dentist in Lakeland, FL
• Providers in Lakeland, FL by specialty
• Dentist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.