Provider Demographics
NPI:1396482329
Name:LAKE WALES SLC OPCO LLC
Entity type:Organization
Organization Name:LAKE WALES SLC OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PILAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-428-2480
Mailing Address - Street 1:941 W MORSE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3781
Mailing Address - Country:US
Mailing Address - Phone:305-428-2480
Mailing Address - Fax:305-428-2480
Practice Address - Street 1:12 E GROVE AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4760
Practice Address - Country:US
Practice Address - Phone:863-679-8146
Practice Address - Fax:863-422-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility