MEDICARE: 1957 N. LAKEMAN AVENUE OPERATING COMPANY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003815762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1957 N. LAKEMAN AVENUE OPERATING COMPANY, LLC

Provider Business Mailing Address
First Line	:	1957 N LAKEMAN DR
Second Line	:
City	:	BELLBROOK
State	:	OH
Zip	:	45305-1212
Country	:	US
Telephone Number	:	937-848-7800
Fax Number	:	937-848-5683

Provider Business Practice Location Address
First Line	:	1957 N LAKEMAN DR
Second Line	:
City	:	BELLBROOK
State	:	OH
Zip	:	45305-1212
Country	:	US
Telephone Number	:	937-848-7800
Fax Number	:	937-848-5683

Authorized Official
Title or Position	:	EXECUTIVE VICE PRES.
Name	:	ANDROSKY ALBERTO LUGO
Credential	:	ESQ.
Telephone Number	:	201-242-4006

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	11/15/2012

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