Provider Demographics
NPI:1497741276
Name:LAKE LODGE NURSING AND REHABILITATION LP
Entity Type:Organization
Organization Name:LAKE LODGE NURSING AND REHABILITATION LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FLAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-387-4388
Mailing Address - Street 1:419 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-6085
Mailing Address - Country:US
Mailing Address - Phone:940-387-4388
Mailing Address - Fax:940-380-2410
Practice Address - Street 1:3800 MARINA DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2835
Practice Address - Country:US
Practice Address - Phone:817-237-7231
Practice Address - Fax:817-237-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1551632 01OtherTMHP CROSS OVER
TX001004353Medicaid
TX1551632 01OtherTMHP CROSS OVER