MEDICARE: SURREY PLACE OF LACANTO 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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588665251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURREY PLACE OF LACANTO LLC

Provider Business Mailing Address
First Line	:	2123 CENTRE POINTE BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4930
Country	:	US
Telephone Number	:	850-386-2831
Fax Number	:	850-386-2016

Provider Business Practice Location Address
First Line	:	2730 W MARC KNIGHTON CT
Second Line	:
City	:	LECANTO
State	:	FL
Zip	:	34461-8334
Country	:	US
Telephone Number	:	352-746-9500
Fax Number	:	352-746-9666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSEPH D. MITCHELL
Credential	:
Telephone Number	:	850-386-2831

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	03/18/2014

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