Provider Demographics
NPI:1225046584
Name:EAGLE LAKE FOUNDATION INC
Entity Type:Organization
Organization Name:EAGLE LAKE FOUNDATION INC
Other - Org Name:EAGLE LAKE REHAB & CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF ACCT & FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEBBELN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-723-3000
Mailing Address - Street 1:24641 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-5007
Mailing Address - Country:US
Mailing Address - Phone:727-723-3000
Mailing Address - Fax:727-723-3076
Practice Address - Street 1:1100 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-6224
Practice Address - Country:US
Practice Address - Phone:727-345-9331
Practice Address - Fax:727-345-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF15650961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031106500Medicaid
FLL43OtherBLUE CROSS PROVIDER #
FL031106500Medicaid