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NPI Code Detail

MEDICARE: LAKE CITY NURSING AND REHABILITATION CENTER, LLC

MEDICARE: LAKE CITY NURSING AND REHABILITATION CENTER, 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
1314000000XSkilled Nursing Facility10311849GA

Other Identifiers

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

General Provider Information

NPI Number : 1053420729
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE CITY NURSING AND REHABILITATION CENTER, LLC
Provider Business Mailing Address
First Line : PO BOX 428
Second Line :
City : ORCHARD PARK
State : NY
Zip : 14127-0428
Country : US
Telephone Number : 716-662-4955
Fax Number : 716-667-9230
Provider Business Practice Location Address
First Line : 2055 REX RD
Second Line :
City : LAKE CITY
State : GA
Zip : 30260-3944
Country : US
Telephone Number : 404-361-5114
Fax Number : 404-363-6366
Authorized Official
Title or Position : CO-CEO
Name : MR. NORBERT A BENNETT
Credential :
Telephone Number : 716-662-4955
Provider Enumeration Date : 08/29/2006
Last Update Date : 12/08/2023

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