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General NPI Number Information
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NPI Number | 1225046584
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Entity Type | Organization
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Legal Business Name | EAGLE LAKE FOUNDATION INC
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 11/05/2010
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Provider Practice Location Address
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Address Line | 1100 66TH ST N
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City | ST PETERSBURG
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State | FL
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Zip | 33710-6224
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Country | US
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Telephone | 727-345-9331
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Fax | 727-345-7064
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Provider Business Mailing Address
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Address Line | 24641 US HIGHWAY 19 N
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City | CLEARWATER
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State | FL
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Zip | 33763-5007
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Country | US
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Telephone | 727-723-3000
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Fax | 727-723-3076
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Authorized Official
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Title or Position | VP OF ACCT & FINANCE
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Name | LYNDA HEBBELN
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Credential |
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Telephone | 727-723-3000
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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 | SNF15650961
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License Number State | FL
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