Healthcare Provider Details

I. General information

NPI: 1013070002
Provider Name (Legal Business Name): LAKE WORTH ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 12TH AVE S
LAKE WORTH FL
33460-5409
US

IV. Provider business mailing address

1201 12TH AVE S
LAKE WORTH FL
33460-5409
US

V. Phone/Fax

Practice location:
  • Phone: 561-586-7404
  • Fax: 561-586-7404
Mailing address:
  • Phone: 561-586-7404
  • Fax: 561-586-7404

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. NELSON ROBAINA
Title or Position: REIMBURSEMENT
Credential:
Phone: 305-864-9191