Healthcare Provider Details

I. General information

NPI: 1184876914
Provider Name (Legal Business Name): LAKE PARK OF MADISON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 SW CAPTAIN BROWN RD
MADISON FL
32340-4316
US

IV. Provider business mailing address

PO BOX 3343
HICKORY NC
28603-3343
US

V. Phone/Fax

Practice location:
  • Phone: 850-973-8277
  • Fax: 850-973-4006
Mailing address:
  • Phone: 828-324-8898
  • Fax: 828-322-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF16360961
License Number StateFL

VIII. Authorized Official

Name: MR. STEVEN D WOMACK
Title or Position: MANAGING MEMBER
Credential:
Phone: 828-324-8898