Healthcare Provider Details

I. General information

NPI: 1225046584
Provider Name (Legal Business Name): EAGLE LAKE FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 66TH ST N
ST PETERSBURG FL
33710-6224
US

IV. Provider business mailing address

24641 US HIGHWAY 19 N
CLEARWATER FL
33763-5007
US

V. Phone/Fax

Practice location:
  • Phone: 727-345-9331
  • Fax: 727-345-7064
Mailing address:
  • Phone: 727-723-3000
  • Fax: 727-723-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF15650961
License Number StateFL

VIII. Authorized Official

Name: LYNDA HEBBELN
Title or Position: VP OF ACCT & FINANCE
Credential:
Phone: 727-723-3000