Provider Demographics
NPI:1245228279
Name:ISLAND LAKE CENTER, LLC
Entity Type:Organization
Organization Name:ISLAND LAKE CENTER, LLC
Other - Org Name:ISLAND LAKE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-852-7000
Mailing Address - Street 1:155 LANDOVER PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4924
Mailing Address - Country:US
Mailing Address - Phone:407-830-7744
Mailing Address - Fax:407-830-7926
Practice Address - Street 1:155 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4924
Practice Address - Country:US
Practice Address - Phone:407-830-7744
Practice Address - Fax:407-830-7926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF13460963314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026065700Medicaid
FL71-00367OtherEVERCARE HH CONNECTION
FL0004438180OtherAETNA
FLC1055643OtherUNITED AMERICAN
FLK3SOtherBLUE CROSS BLUE SHIELD
FLK3SOtherBLUE CROSS BLUE SHIELD
105643Medicare Oscar/Certification