Basic Information
| Provider Information | |||||||||
| NPI: | 1780676049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENSACOLA HEALTH TRUST INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 N PALAFOX ST | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325025631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504300000 | ||||||||
| FaxNumber: | 8504366766 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 HIGHWAY 511 | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393558320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017762141 | ||||||||
| FaxNumber: | 6017765782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8504300000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 290 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0230104 | 05 | MS | MEDICAID |