Provider Demographics
NPI:1326043050
Name:LADY LAKE NH, LLC
Entity Type:Organization
Organization Name:LADY LAKE NH, LLC
Other - Org Name:LADY LAKE SPECIALTY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-557-6200
Mailing Address - Street 1:630 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8101
Mailing Address - Country:US
Mailing Address - Phone:352-750-6619
Mailing Address - Fax:352-750-0373
Practice Address - Street 1:630 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8101
Practice Address - Country:US
Practice Address - Phone:352-750-6619
Practice Address - Fax:352-750-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF130470994314000000X
332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0227561-00Medicaid
FL106003Medicare Oscar/Certification
FL5550780001Medicare NSC