Healthcare Provider Details

I. General information

NPI: 1073500310
Provider Name (Legal Business Name): LAKE PRINCE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ANNA GOODE WAY
SUFFOLK VA
23434-9236
US

IV. Provider business mailing address

100 ANNA GOODE WAY
SUFFOLK VA
23434-9236
US

V. Phone/Fax

Practice location:
  • Phone: 757-923-5500
  • Fax: 757-923-5502
Mailing address:
  • Phone: 757-923-5500
  • Fax: 757-923-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2752
License Number StateVA

VIII. Authorized Official

Name: PAULA SUTTON WHITE
Title or Position: ACCOUNTS RECEIVABLE MANAGER
Credential:
Phone: 828-465-8021