1225046584 NPI number — EAGLE LAKE FOUNDATION INC

Table of content: (NPI 1225046584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225046584 NPI number — EAGLE LAKE FOUNDATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE LAKE FOUNDATION INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EAGLE LAKE REHAB & CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225046584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24641 US HIGHWAY 19 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33763-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-723-3000
Provider Business Mailing Address Fax Number:
727-723-3076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 66TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33710-6224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-345-9331
Provider Business Practice Location Address Fax Number:
727-345-7064
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEBBELN
Authorized Official First Name:
LYNDA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF ACCT & FINANCE
Authorized Official Telephone Number:
727-723-3000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF15650961 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 031106500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: L43 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 013823900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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