Healthcare Provider Details

I. General information

NPI: 1699667691
Provider Name (Legal Business Name): LAKE WAY SNF OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 MAIN ST
BENTON KY
42025-7601
US

IV. Provider business mailing address

2607 MAIN ST
BENTON KY
42025-7601
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-3296
  • 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: MENUCHA GOODMAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 848-201-8402