Basic Information
| Provider Information | |||||||||
| NPI: | 1184876914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE PARK OF MADISON, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE PARK OF MADISON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3343 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286033343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283248898 | ||||||||
| FaxNumber: | 8283229598 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 SW CAPTAIN BROWN RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323404316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509738277 | ||||||||
| FaxNumber: | 8509734006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOMACK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8283248898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF16360961 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.