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NPI Code Detail

MEDICARE: CCRC - LAKE PORT SQUARE, LLC

MEDICARE: CCRC - LAKE PORT SQUARE, 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 Facility

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 : 1073927331
Entity Type Code : Organization
Provider Name (Legal Business Name) : CCRC - LAKE PORT SQUARE, LLC
Provider Business Mailing Address
First Line : 1920 MAIN ST STE 1200
Second Line :
City : IRVINE
State : CA
Zip : 92614-7230
Country : US
Telephone Number : 949-407-0700
Fax Number :
Provider Business Practice Location Address
First Line : 701 LAKE PORT BLVD
Second Line :
City : LEESBURG
State : FL
Zip : 34748-7674
Country : US
Telephone Number : 352-728-3366
Fax Number :
Authorized Official
Title or Position : ADMINISTRATOR
Name : TRISTAN MOHADEO
Credential :
Telephone Number : 352-728-8525
Provider Enumeration Date : 06/16/2014
Last Update Date : 01/19/2026

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