Healthcare Provider Details

I. General information

NPI: 1972505949
Provider Name (Legal Business Name): LAKEWOOD NURSING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N LAKE ST
CRESCENT CITY FL
32112-2620
US

IV. Provider business mailing address

100 N LAKE ST
CRESCENT CITY FL
32112-2620
US

V. Phone/Fax

Practice location:
  • Phone: 386-698-2222
  • Fax: 386-698-2717
Mailing address:
  • Phone: 386-698-2222
  • Fax: 386-698-2717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBERT W HAGAN
Title or Position: PRESIDENT
Credential:
Phone: 770-993-4000