Provider Demographics
NPI:1275556383
Name:2900 TWELFTH STREET NORTH LLC
Entity Type:Organization
Organization Name:2900 TWELFTH STREET NORTH LLC
Other - Org Name:LAKESIDE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TENNESSEE
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:505-468-4742
Mailing Address - Fax:505-468-8742
Practice Address - Street 1:2900 12TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4528
Practice Address - Country:US
Practice Address - Phone:239-261-2554
Practice Address - Fax:239-261-4540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF 12840962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025684600Medicaid
105439Medicare Oscar/Certification