MEDICARE: LAKELAND VILLAGE NURSING FACILITY

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	313M00000X	Nursing Facility/Intermediate Care Facility	00L020	WA

General Provider Information

NPI Number	:	1780734509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKELAND VILLAGE NURSING FACILITY

Provider Business Mailing Address
First Line	:	PO BOX 200
Second Line	:
City	:	MEDICAL LAKE
State	:	WA
Zip	:	99022-0200
Country	:	US
Telephone Number	:	509-299-1989
Fax Number	:	509-299-1070

Provider Business Practice Location Address
First Line	:	S 2320 SALNAVE ROAD
Second Line	:
City	:	MEDICAL LAKE
State	:	WA
Zip	:	99022-0200
Country	:	US
Telephone Number	:	509-299-1989
Fax Number	:	509-299-1070

Authorized Official
Title or Position	:	ASSISTANT SUPERINTENDENT
Name	:	MR. STEVEN EARL KELLEN
Credential	:	LNHA
Telephone Number	:	509-299-1989

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	06/20/2008

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Directions to “LAKELAND VILLAGE NURSING FACILITY ” Practice Location

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