Provider Demographics
NPI:1568423234
Name:MERIDIAN PARK VILLAGE LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:MERIDIAN PARK VILLAGE LIMITED PARTNERSHIP
Other - Org Name:VI AT LAKESIDE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-803-8555
Mailing Address - Street 1:2792 DONNELLY DR
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6431
Mailing Address - Country:US
Mailing Address - Phone:561-966-4600
Mailing Address - Fax:561-434-5344
Practice Address - Street 1:2792 DONNELLY DR
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-6431
Practice Address - Country:US
Practice Address - Phone:561-966-4600
Practice Address - Fax:561-434-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9045310400000X
FLSNF130470976314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105968Medicare Oscar/Certification