MEDICARE: LAKES QUALITY CARE, INC.

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	310400000X	Assisted Living Facility	AL12199	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AL12199	OTHER	FL	AHCA LICENSE NUMBER

General Provider Information

NPI Number	:	1669736492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES QUALITY CARE, INC.

Provider Business Mailing Address
First Line	:	3661 NW 29TH ST
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33311-1846
Country	:	US
Telephone Number	:	954-730-8800
Fax Number	:	954-730-8800

Provider Business Practice Location Address
First Line	:	3661 NW 29TH ST
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33311-1846
Country	:	US
Telephone Number	:	954-730-8800
Fax Number	:	954-730-8800

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANGELLA ELLIOTT
Credential	:
Telephone Number	:	954-730-8800

Provider Enumeration Date	:	06/26/2012
Last Update Date	:	06/26/2012

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Directions to “LAKES QUALITY CARE, INC. ” Practice Location

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