Basic Information
| Provider Information | |||||||||
| NPI: | 1407270432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LL, FORT MYERS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAMPLIGHT INN OF FORT MYERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7444 LONG AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | 8473294900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1896 PARK MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399395421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 02/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | PETRAS | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2607979482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL5096 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | AL5096 | 01 | FL | RESIDENTIAL CARE FACILITY LICENSE | OTHER |