Healthcare Provider Details

I. General information

NPI: 1104519925
Provider Name (Legal Business Name): LAKE MORTON SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FLORIDA AVE S
LAKELAND FL
33801-5254
US

IV. Provider business mailing address

5801 ULMERTON RD STE 200
CLEARWATER FL
33760-3951
US

V. Phone/Fax

Practice location:
  • Phone: 863-683-1000
  • Fax:
Mailing address:
  • Phone: 727-683-1200
  • 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: KEVIN TAPP
Title or Position: REGIONAL DIRECTOR OF OPERATIONS
Credential:
Phone: 727-418-3148