Provider Demographics
NPI:1477559672
Name:SA-LAKELAND, LLC
Entity Type:Organization
Organization Name:SA-LAKELAND, LLC
Other - Org Name:PALM TERRACE OF LAKELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-390-4363
Mailing Address - Street 1:1919 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2901
Mailing Address - Country:US
Mailing Address - Phone:863-688-5612
Mailing Address - Fax:863-688-1398
Practice Address - Street 1:1919 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2901
Practice Address - Country:US
Practice Address - Phone:863-688-5612
Practice Address - Fax:863-687-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14530961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL028262600Medicaid
FL105354Medicare Oscar/Certification