Provider Demographics
NPI:1568444792
Name:SIGNATURE PROPERTIES OF LAKE PARK, LLC
Entity type:Organization
Organization Name:SIGNATURE PROPERTIES OF LAKE PARK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:MEHLHOP
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:515-727-1770
Mailing Address - Street 1:1304 SOUTH MARKET
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:IA
Mailing Address - Zip Code:51347-1060
Mailing Address - Country:US
Mailing Address - Phone:712-832-3691
Mailing Address - Fax:712-832-9548
Practice Address - Street 1:1304 SOUTH MARKET
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:IA
Practice Address - Zip Code:51347-1060
Practice Address - Country:US
Practice Address - Phone:712-832-3691
Practice Address - Fax:712-832-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA300598314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0809731Medicaid
165445Medicare Oscar/Certification