Healthcare Provider Details

I. General information

NPI: 1740514496
Provider Name (Legal Business Name): LAKE BENNETT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 KELTON AVE
OCOEE FL
34761-3162
US

IV. Provider business mailing address

1091 KELTON AVE
OCOEE FL
34761-3162
US

V. Phone/Fax

Practice location:
  • Phone: 850-258-0316
  • Fax: 850-392-0000
Mailing address:
  • Phone: 850-258-0316
  • Fax: 850-392-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOHN EARL WARREN
Title or Position: PRESIDENT
Credential:
Phone: 850-258-0316