Provider Demographics
NPI:1376964403
Name:LAKEWALES HEALTH CARE OPERATIONS COMPANY, LLC
Entity Type:Organization
Organization Name:LAKEWALES HEALTH CARE OPERATIONS COMPANY, LLC
Other - Org Name:BELLATAGE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-664-5400
Mailing Address - Street 1:1800 N WABASH RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1300
Mailing Address - Country:US
Mailing Address - Phone:765-664-5400
Mailing Address - Fax:765-664-5403
Practice Address - Street 1:701 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1671
Practice Address - Country:US
Practice Address - Phone:863-318-5000
Practice Address - Fax:863-324-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11898310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility