Provider Demographics
NPI:1265837314
Name:LANIER TERRACE LLC
Entity Type:Organization
Organization Name:LANIER TERRACE LLC
Other - Org Name:LANIER TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-366-0254
Mailing Address - Street 1:12740 LANIER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-1704
Mailing Address - Country:US
Mailing Address - Phone:386-366-0254
Mailing Address - Fax:305-899-0201
Practice Address - Street 1:12740 LANIER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-1704
Practice Address - Country:US
Practice Address - Phone:386-366-0254
Practice Address - Fax:305-899-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105666Medicare Oscar/Certification