Provider Demographics
NPI:1477846129
Name:KAN LAKE CORPORATION INC.
Entity Type:Organization
Organization Name:KAN LAKE CORPORATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAMLAWATY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKRAM
Authorized Official - Suffix:
Authorized Official - Credentials:CORE
Authorized Official - Phone:772-519-4327
Mailing Address - Street 1:308 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-7205
Mailing Address - Country:US
Mailing Address - Phone:772-519-4327
Mailing Address - Fax:
Practice Address - Street 1:308 S 30TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-7205
Practice Address - Country:US
Practice Address - Phone:772-519-4327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL90253104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141943900Medicaid