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General NPI Number Information
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NPI Number | 1194920488
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Entity Type | Organization
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Legal Business Name | LAKEWOOD ADULT FAMILY HOME INC
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Dates
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Enumeration Date | 06/18/2007
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 69 RAINBOWS END
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City | BOMOSEEN
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State | VT
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Zip | 05732-4417
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Country | US
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Telephone | 802-468-3010
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Fax | 802-468-5374
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Provider Business Mailing Address
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Address Line | POB 1543
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City | CASTLETON
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State | VT
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Zip | 05735-1543
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Country | US
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Telephone | 802-468-3010
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Fax | 802-468-5374
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. RICHARD JAMES CHURCH
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Credential |
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Telephone | 802-468-3010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 544
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License Number State | VT
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