Healthcare Provider Details

I. General information

NPI: 1932601747
Provider Name (Legal Business Name): LAKE PRINCE AT HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ANNA GOODE WAY
SUFFOLK VA
23434-9236
US

IV. Provider business mailing address

100 LEONARD AVE
NEWTON NC
28658-9649
US

V. Phone/Fax

Practice location:
  • Phone: 757-923-5500
  • Fax:
Mailing address:
  • Phone: 828-465-8021
  • Fax: 828-465-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEE B SYRIA
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 828-465-8019