Provider Demographics
NPI:1568764991
Name:BLC TAVARES-GC,LLC
Entity Type:Organization
Organization Name:BLC TAVARES-GC,LLC
Other - Org Name:BROOKDALE LAKE TAVARES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:111 WESTWOOD PL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1211 E CAROLINE ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3460
Practice Address - Country:US
Practice Address - Phone:353-343-6464
Practice Address - Fax:352-343-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility