Healthcare Provider Details

I. General information

NPI: 1205189867
Provider Name (Legal Business Name): LADY LAKE SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HIGHWAY 466
LADY LAKE FL
32159
US

IV. Provider business mailing address

1835 NE MIAMI GARDENS DR #368
NORTH MIAMI BEACH FL
33179-5035
US

V. Phone/Fax

Practice location:
  • Phone: 352-396-6956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: MR. TZVI BOGOMILSKY
Title or Position: AUTHORIZED MEMBER
Credential:
Phone: 305-401-7901