Healthcare Provider Details

I. General information

NPI: 1528207693
Provider Name (Legal Business Name): SOUTHERN LIFESTYLE ALF OF LAKE PLACID LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1297 US 27 N
LAKE PLACID FL
33852-7907
US

IV. Provider business mailing address

1297 US 27 N
LAKE PLACID FL
33852-7907
US

V. Phone/Fax

Practice location:
  • Phone: 863-465-0568
  • Fax: 863-465-0575
Mailing address:
  • Phone: 863-465-0568
  • Fax: 863-465-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11211
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL11211
License Number StateFL

VIII. Authorized Official

Name: MR. CHARLES A OAKES
Title or Position: ADMINISTRATOR
Credential:
Phone: 863-465-0568