MEDICARE: BLUE LAKE POST ACUTE 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

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	:	1710613500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE LAKE POST ACUTE LLC

Provider Business Mailing Address
First Line	:	991 E NEW YORK AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32724-5664
Country	:	US
Telephone Number	:	386-734-9083
Fax Number	:

Provider Business Practice Location Address
First Line	:	991 E NEW YORK AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32724-5664
Country	:	US
Telephone Number	:	386-734-9083
Fax Number	:

Authorized Official
Title or Position	:	LEGAL COUNSEL
Name	:	SCOTT H TANNER
Credential	:
Telephone Number	:	949-430-5178

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	01/19/2023

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Directions to “BLUE LAKE POST ACUTE LLC ” Practice Location

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