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General NPI Number Information
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NPI Number | 1336587708
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Entity Type | Organization
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Legal Business Name | GRACE MANOR AT LAKE MORTON, LLC
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Dates
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Enumeration Date | 06/07/2013
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Last Update Date | 02/16/2022
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Provider Practice Location Address
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Address Line | 610 E LIME STREET
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City | LAKELAND
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State | FL
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Zip | 33801
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Country | US
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Telephone | 863-937-9114
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Fax | 863-937-9117
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Provider Business Mailing Address
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Address Line | 505 ARIANA AVE
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City | AUBURNDALE
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State | FL
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Zip | 33823-4139
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Country | US
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Telephone | 863-226-0358
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Fax | 863-875-9489
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Authorized Official
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Title or Position | ASST. ADMINISTRATOR
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Name | MS. SAVITRI JOHNSON
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Credential |
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Telephone | 863-226-0358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number |
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License Number State |
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