=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356698195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE COUNTY ADULT ACTIVITY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 05/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 CITRUS TOWER BLVD STE 102
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-404-6098
-----------------------------------------------------
Fax | 352-404-6475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 CITRUS TOWER BLVD STE 102
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-404-6098
-----------------------------------------------------
Fax | 352-404-6475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FACILITY DIRECTOR
-----------------------------------------------------
Name | MRS. CAROLINA MARIA GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-404-6098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------