Provider Demographics
NPI:1336162395
Name:LAKE PARKER FACILITY OPERATIONS LLC
Entity type:Organization
Organization Name:LAKE PARKER FACILITY OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:USSERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:2020 W LAKE PARKER DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-5005
Mailing Address - Country:US
Mailing Address - Phone:863-682-7580
Mailing Address - Fax:863-683-9564
Practice Address - Street 1:2020 W LAKE PARKER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-5005
Practice Address - Country:US
Practice Address - Phone:863-682-7580
Practice Address - Fax:863-683-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF10150962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008039300Medicaid
FL031967800Medicaid
5911560001Medicare NSC
FL008039300Medicaid