Basic Information
| Provider Information | |||||||||
| NPI: | 1366499535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANORCARE HEALTH SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA SKILLED NURSING AND REHABILITATION (LELY PALMS) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | ATTN: BARRY LAZARUS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525541 | ||||||||
| FaxNumber: | 4192525548 | ||||||||
| Practice Location | |||||||||
| Address1: | 6135 RATTLESNAKE HAMMOCK RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341132912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397757715 | ||||||||
| FaxNumber: | 2397329765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAZARUS | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - REIMBURSEMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4192525518 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF12930962 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 032542200 | 05 | FL | MEDICAID |