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General NPI Number Information
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NPI Number | 1164540928
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Entity Type | Organization
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Legal Business Name | LAKE COUNTRY HEALTHCARE, LLC
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 10/24/2007
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Provider Practice Location Address
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Address Line | 983 N HIGHWAY 19 (TEXAS STREET)
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City | EMORY
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State | TX
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Zip | 75440-0040
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Country | US
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Telephone | 903-473-3752
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Fax | 903-473-3141
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Provider Business Mailing Address
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Address Line | PO BOX 40
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City | EMORY
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State | TX
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Zip | 75440-0040
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Country | US
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Telephone | 903-473-3752
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Fax | 903-473-3141
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DAVID LEMONS
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Credential | LNFA
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Telephone | 903-473-3752
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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 | TX
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