Provider Demographics
NPI:1528207693
Name:SOUTHERN LIFESTYLE ALF OF LAKE PLACID LLC
Entity Type:Organization
Organization Name:SOUTHERN LIFESTYLE ALF OF LAKE PLACID LLC
Other - Org Name:SOUTHERN LIFESTYLE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:OAKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-465-0568
Mailing Address - Street 1:1297 US 27 N
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-7907
Mailing Address - Country:US
Mailing Address - Phone:863-465-0568
Mailing Address - Fax:863-465-0575
Practice Address - Street 1:1297 US 27 N
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7907
Practice Address - Country:US
Practice Address - Phone:863-465-0568
Practice Address - Fax:863-465-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11211310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000266800OtherMEDICAID WAIVER