Provider Demographics
NPI:1164540928
Name:LAKE COUNTRY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY HEALTHCARE, LLC
Other - Org Name:GREEN ACRES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:903-473-3752
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440-0040
Mailing Address - Country:US
Mailing Address - Phone:903-473-3752
Mailing Address - Fax:903-473-3141
Practice Address - Street 1:983 N HIGHWAY 19 (TEXAS STREET)
Practice Address - Street 2:
Practice Address - City:EMORY
Practice Address - State:TX
Practice Address - Zip Code:75440-0040
Practice Address - Country:US
Practice Address - Phone:903-473-3752
Practice Address - Fax:903-473-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676142Medicare Oscar/Certification