Healthcare Provider Details

I. General information

NPI: 1710317532
Provider Name (Legal Business Name): BVM LAKESHORE LLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 LAKESHORE VILLA DRIVE
TAMPA FL
33613
US

IV. Provider business mailing address

PO BOX 501188
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 813-968-5093
  • Fax: 813-968-5093
Mailing address:
  • Phone: 317-806-6771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1282096
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL7531
License Number StateFL

VIII. Authorized Official

Name: MR. ROBERT L RYNARD SR.
Title or Position: CHAIRMAN / PRESIDENT
Credential:
Phone: 317-627-0504