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General NPI Number Information
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NPI Number | 1114253754
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Entity Type | Organization
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Legal Business Name | SHADY LANE RETIREMENT HOME
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Dates
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Enumeration Date | 11/01/2009
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Last Update Date | 11/01/2009
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Provider Practice Location Address
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Address Line | 201 ROSEFIELD AVE
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City | LEESBURG
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State | FL
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Zip | 34748-5014
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Country | US
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Telephone | 352-728-1559
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Fax | 352-728-1703
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Provider Business Mailing Address
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Address Line | 201 ROSEFIELD AVE
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City | LEESBURG
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State | FL
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Zip | 34748-5014
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Country | US
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Telephone | 352-728-1559
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Fax |
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MR. SEGUNDO LIZARDO
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Credential |
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Telephone | 352-728-1559
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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 | AL6001
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License Number State | FL
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