MEDICARE: LAKE MARIAM FL OPCO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1114621851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MARIAM FL OPCO LLC

Provider Business Mailing Address
First Line	:	1801 LAKE MARIAM DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-0927
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 LAKE MARIAM DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-0927
Country	:	US
Telephone Number	:	863-293-1989
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BATYA GORELICK
Credential	:
Telephone Number	:	201-928-7808

Provider Enumeration Date	:	03/28/2023
Last Update Date	:	03/28/2023

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Directions to “LAKE MARIAM FL OPCO LLC ” Practice Location

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