Healthcare Provider Details

I. General information

NPI: 1366439952
Provider Name (Legal Business Name): SPRING LAKE NC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 6TH ST NW
WINTER HAVEN FL
33881-2368
US

IV. Provider business mailing address

1540 6TH ST NW
WINTER HAVEN FL
33881-2368
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-3055
  • Fax: 863-294-4210
Mailing address:
  • Phone: 863-294-3055
  • Fax: 863-294-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF15110961
License Number StateFL

VIII. Authorized Official

Name: MR. SAMUEL B. KELLETT
Title or Position: AS SOLE MEMBER OF SBK CAPITAL LLC
Credential:
Phone: 404-233-7048