MEDICARE: SUMMIT VIEW OF LAKE CITY, 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

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
2	114355	OTHER	TN	BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164431003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT VIEW OF LAKE CITY, LLC

Provider Business Mailing Address
First Line	:	204 INDUSTRIAL PARK LN
Second Line	:
City	:	LAKE CITY
State	:	TN
Zip	:	37769-2301
Country	:	US
Telephone Number	:	865-426-2147
Fax Number	:	865-426-7144

Provider Business Practice Location Address
First Line	:	204 INDUSTRIAL PARK LN
Second Line	:
City	:	LAKE CITY
State	:	TN
Zip	:	37769-2301
Country	:	US
Telephone Number	:	865-426-2147
Fax Number	:	865-426-7144

Authorized Official
Title or Position	:	OWNER, PRESIDENT
Name	:	MR. RONALD E LAWRENCE
Credential	:	NHA, MBA
Telephone Number	:	865-675-6444

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	01/20/2021

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