Provider Demographics
NPI:1114323805
Name:THE MANOR AT LAKE JACKSON MEMORY CARE
Entity Type:Organization
Organization Name:THE MANOR AT LAKE JACKSON MEMORY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:GARRARD
Authorized Official - Suffix:V
Authorized Official - Credentials:
Authorized Official - Phone:863-226-0358
Mailing Address - Street 1:505 ARIANA AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-4139
Mailing Address - Country:US
Mailing Address - Phone:863-226-0358
Mailing Address - Fax:863-510-5952
Practice Address - Street 1:2301 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-4941
Practice Address - Country:US
Practice Address - Phone:863-471-0772
Practice Address - Fax:863-471-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110938100Medicaid