=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730053745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE CITY CENTER FOR NURSING AND HEALING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2025
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 REX RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-361-1028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2055 REX RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-361-1028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER OF LLC
-----------------------------------------------------
Name | SHLOMO E HELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-737-0111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------