Provider Demographics
NPI:1093222515
Name:ANTHEM LAKES
Entity Type:Organization
Organization Name:ANTHEM LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS LIAISON
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNPAUL
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-839-6946
Mailing Address - Street 1:905 ASSISI LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32233-2972
Mailing Address - Country:US
Mailing Address - Phone:904-746-7220
Mailing Address - Fax:
Practice Address - Street 1:905 ASSISI LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32233-2972
Practice Address - Country:US
Practice Address - Phone:904-746-7220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12972310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility