1376964403 NPI number — LAKEWALES HEALTH CARE OPERATIONS COMPANY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376964403 NPI number — LAKEWALES HEALTH CARE OPERATIONS COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWALES HEALTH CARE OPERATIONS COMPANY, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1376964403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 N WABASH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46952-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-664-5400
Provider Business Mailing Address Fax Number:
765-664-5403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 OVERLOOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33884-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-318-5000
Provider Business Practice Location Address Fax Number:
863-324-7251
Provider Enumeration Date:
12/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
CULLEN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
VICE PRESIDENT/MEMBER
Authorized Official Telephone Number:
765-664-5400

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL11898 , 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)





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