Provider Demographics
NPI:1033110457
Name:SCG LAKE COUNTRY LLC
Entity Type:Organization
Organization Name:SCG LAKE COUNTRY LLC
Other - Org Name:LAKE COUNTRY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-341-2700
Mailing Address - Street 1:1240 MARBELLA PLAZA DR.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7905
Mailing Address - Country:US
Mailing Address - Phone:813-341-2700
Mailing Address - Fax:813-676-0127
Practice Address - Street 1:401 C E COLSTON DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OK
Practice Address - Zip Code:73448-1230
Practice Address - Country:US
Practice Address - Phone:580-276-3318
Practice Address - Fax:580-276-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4301-4301314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776270AMedicaid
OK37-5310Medicare Oscar/Certification