MEDICARE: LAKE WALES OPERATING GROUP 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	:	1790348829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WALES OPERATING GROUP LLC

Provider Business Mailing Address
First Line	:	544 PARK AVE STE B04
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11205-1670
Country	:	US
Telephone Number	:	917-682-3129
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 N SCENIC HWY
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-3208
Country	:	US
Telephone Number	:	863-676-1512
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	ANSHEL NIEDERMAN
Credential	:
Telephone Number	:	929-900-2005

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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