Healthcare Provider Details

I. General information

NPI: 1164391082
Provider Name (Legal Business Name): PCP LADY LAKE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 S US HIGHWAY 441
LADY LAKE FL
32159
US

IV. Provider business mailing address

2573 BARRINGTON CIR
TALLAHASSEE FL
32308-6805
US

V. Phone/Fax

Practice location:
  • Phone: 352-268-3523
  • Fax:
Mailing address:
  • Phone: 850-583-7990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: SETH WALKER
Title or Position: CFO
Credential:
Phone: 850-583-7990