Provider Demographics
NPI:1366439952
Name:SPRING LAKE NC, LLC
Entity Type:Organization
Organization Name:SPRING LAKE NC, LLC
Other - Org Name:SPRING LAKE REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AS SOLE MEMBER OF SBK CAPITAL LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-233-7048
Mailing Address - Street 1:1540 6TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-2368
Mailing Address - Country:US
Mailing Address - Phone:863-294-3055
Mailing Address - Fax:863-294-4210
Practice Address - Street 1:1540 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2368
Practice Address - Country:US
Practice Address - Phone:863-294-3055
Practice Address - Fax:863-294-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF15110961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026457100Medicaid
V673P-5338OtherVA
105730Medicare ID - Type Unspecified