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General NPI Number Information
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NPI Number | 1477846129
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Entity Type | Organization
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Legal Business Name | KAN LAKE CORPORATION INC.
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 308 S 30TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34947-7205
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Country | US
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Telephone | 772-519-4327
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Fax |
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Provider Business Mailing Address
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Address Line | 308 S 30TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34947-7205
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Country | US
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Telephone | 772-519-4327
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KAMLAWATY LAKRAM
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Credential | CORE
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Telephone | 772-519-4327
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | AL9025
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License Number State | FL
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