Provider Demographics
NPI:1417153446
Name:NORTH LAKE RETIREMENT HOME
Entity Type:Organization
Organization Name:NORTH LAKE RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ADM
Authorized Official - Prefix:MR
Authorized Official - First Name:PASCAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-922-2643
Mailing Address - Street 1:1222 N 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-3741
Mailing Address - Country:US
Mailing Address - Phone:954-922-2643
Mailing Address - Fax:
Practice Address - Street 1:1222 N 16TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-3741
Practice Address - Country:US
Practice Address - Phone:954-922-2643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7395310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility