Provider Demographics
NPI:1437169513
Name:LAKE VILLAGE HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:LAKE VILLAGE HEALTHCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTERWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-527-4083
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:STE 503 EXECUTIVE PLAZA III
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-527-4083
Mailing Address - Fax:410-527-4081
Practice Address - Street 1:903 BORGOGNON DR
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-265-5337
Practice Address - Fax:870-265-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15403311Medicaid
AR15403311Medicaid