Basic Information
| Provider Information | |||||||||
| NPI: | 1457726838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GV LAKELAND, LLC | ||||||||
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| OtherOrganizationName: | GRAND VILLA OF LAKELAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13770 58TH ST N | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
| FaxNumber: | 7277265345 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338052905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8366881126 | ||||||||
| FaxNumber: | 8636833326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | SIZEMORE | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7277263980 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL 6107 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.