Healthcare Provider Details

I. General information

NPI: 1114621851
Provider Name (Legal Business Name): LAKE MARIAM FL OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 LAKE MARIAM DR
WINTER HAVEN FL
33884-0927
US

IV. Provider business mailing address

1801 LAKE MARIAM DR
WINTER HAVEN FL
33884-0927
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-1989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BATYA GORELICK
Title or Position: MANAGER
Credential:
Phone: 201-928-7808