Provider Demographics
NPI:1083788053
Name:LAKELAND NURSING AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:LAKELAND NURSING AND REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-4955
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-0428
Mailing Address - Country:US
Mailing Address - Phone:716-662-4955
Mailing Address - Fax:716-667-9230
Practice Address - Street 1:3680 LAKELAND LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4707
Practice Address - Country:US
Practice Address - Phone:601-982-5505
Practice Address - Fax:601-362-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS385314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000071705Medicaid
MS000080392OtherBC BS OF MISSISSIPPI
MS00071705Medicaid