Healthcare Provider Details

I. General information

NPI: 1457726838
Provider Name (Legal Business Name): GV LAKELAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 LAKELAND HILLS BLVD
LAKELAND FL
33805-2905
US

IV. Provider business mailing address

13770 58TH ST N SUITE 312
CLEARWATER FL
33760-3759
US

V. Phone/Fax

Practice location:
  • Phone: 836-688-1126
  • Fax: 863-683-3326
Mailing address:
  • Phone: 727-726-3980
  • Fax: 727-726-5345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL 6107
License Number StateFL

VIII. Authorized Official

Name: JOHNNY SIZEMORE
Title or Position: OPERATIONS COORDINATOR
Credential:
Phone: 727-726-3980