Basic Information
Provider Information | |||||||||
NPI: | 1720089394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKELAND INVESTORS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALENCIA HILLS HEALTH & REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2123 CENTRE POINTE BLVD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323084930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8503862831 | ||||||||
FaxNumber: | 8503862016 | ||||||||
Practice Location | |||||||||
Address1: | 1350 SLEEPY HILL RD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338103800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8638584402 | ||||||||
FaxNumber: | 8638586759 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2005 | ||||||||
LastUpdateDate: | 01/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MITCHELL | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8503862831 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 026556000 | 05 | FL |   | MEDICAID |