Healthcare Provider Details

I. General information

NPI: 1568456614
Provider Name (Legal Business Name): DELANEY CREEK LODGE, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S LAKEWOOD DR
BRANDON FL
33511-0809
US

IV. Provider business mailing address

440 LAFAYETTE AVE SUITE 400
CINCINNATI OH
45220-1022
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-8858
  • Fax: 813-655-1079
Mailing address:
  • Phone: 513-487-3600
  • Fax: 513-487-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9582
License Number StateFL

VIII. Authorized Official

Name: CARLA BROOKS
Title or Position: CFO - DEACONESS LONG TERM CARE, INC
Credential:
Phone: 513-487-3600