MEDICARE: LAKE CITY MGT 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	SNF15510961	FL

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	:	1750365706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CITY MGT LLC

Provider Business Mailing Address
First Line	:	1270 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-752-7900
Fax Number	:	386-752-8556

Provider Business Practice Location Address
First Line	:	1270 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-752-7900
Fax Number	:	386-752-8556

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LAVERN PATRICK HERZOG
Credential	:
Telephone Number	:	386-956-6956

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	10/08/2020

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Directions to “LAKE CITY MGT LLC ” Practice Location

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