Provider Demographics
NPI:1124418975
Name:SOUTH LAKE HOSPITAL INC
Entity Type:Organization
Organization Name:SOUTH LAKE HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-394-4071
Mailing Address - Street 1:1900 DON WICKHAM DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1979
Mailing Address - Country:US
Mailing Address - Phone:352-394-4071
Mailing Address - Fax:352-241-7124
Practice Address - Street 1:2145 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-536-8787
Practice Address - Fax:352-241-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4180314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility