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General NPI Number Information
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NPI Number | 1710613500
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Entity Type | Organization
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Legal Business Name | BLUE LAKE POST ACUTE LLC
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Dates
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Enumeration Date | 07/25/2022
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Last Update Date | 01/19/2023
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Provider Practice Location Address
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Address Line | 991 E NEW YORK AVE
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City | DELAND
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State | FL
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Zip | 32724-5664
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Country | US
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Telephone | 386-734-9083
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Fax |
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Provider Business Mailing Address
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Address Line | 991 E NEW YORK AVE
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City | DELAND
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State | FL
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Zip | 32724-5664
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Country | US
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Telephone | 386-734-9083
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Fax |
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Authorized Official
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Title or Position | LEGAL COUNSEL
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Name | SCOTT H TANNER
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Credential |
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Telephone | 949-430-5178
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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 |
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License Number State |
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