Provider Demographics
NPI:1205026382
Name:LP PALM BAY LLC
Entity Type:Organization
Organization Name:LP PALM BAY LLC
Other - Org Name:ANCHOR CARE & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-7800
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7800
Mailing Address - Fax:502-568-7150
Practice Address - Street 1:1515 PORT MALABAR BLVD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5437
Practice Address - Country:US
Practice Address - Phone:321-723-1235
Practice Address - Fax:321-951-2630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LP O HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14040951314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
6103560001Medicare NSC
FL105464Medicare Oscar/Certification