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General NPI Number Information
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NPI Number | 1104133115
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Entity Type | Organization
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Legal Business Name | EAST LAKE MANOR, INC
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Dates
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Enumeration Date | 09/13/2010
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Last Update Date | 09/13/2010
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Provider Practice Location Address
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Address Line | 722 EAST LAKE ROAD S.
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City | TARPON SPRINGS
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State | FL
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Zip | 34688
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Country | US
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Telephone | 727-934-4791
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Fax | 727-934-1791
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Provider Business Mailing Address
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Address Line | 722 EAST LAKE ROAD S.
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City | TARPON SPRINGS
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State | FL
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Zip | 34688
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Country | US
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Telephone | 727-934-4791
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Fax | 727-934-1791
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Authorized Official
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Title or Position | ADMINISTRATOR / OWNER
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Name | MR. SYLVESTER REMORCA
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Credential |
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Telephone | 848-333-2670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 9773
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License Number State | FL
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