1609877976 NPI number — SOUTH LAKE HOSPITAL, INC.

Table of content: (NPI 1609877976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609877976 NPI number — SOUTH LAKE HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH LAKE HOSPITAL, 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:
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:
1609877976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 DON WICKHAM DRIVE
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-241-7138
Provider Business Mailing Address Fax Number:
352-241-7248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 CITRUS TOWER BLVD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-241-7138
Provider Business Practice Location Address Fax Number:
352-241-7248
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLACHTER
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF NURSING
Authorized Official Telephone Number:
352-241-7138

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA210740962 , 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: 650128100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: J5Y . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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