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General NPI Number Information
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NPI Number | 1073927331
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Entity Type | Organization
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Legal Business Name | CCRC - LAKE PORT SQUARE, LLC
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Dates
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Enumeration Date | 06/16/2014
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Last Update Date | 05/29/2025
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Provider Practice Location Address
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Address Line | 701 LAKE PORT BLVD
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City | LEESBURG
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State | FL
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Zip | 34748-7674
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Country | US
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Telephone | 352-728-3366
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Fax |
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Provider Business Mailing Address
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Address Line | 1920 MAIN ST STE 1200
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City | IRVINE
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State | CA
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Zip | 92614-7230
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Country | US
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Telephone | 949-407-0700
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TRISTAN MOHADEO
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Credential |
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Telephone | 352-728-8525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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