Provider Demographics
NPI:1588665251
Name:SURREY PLACE OF LACANTO LLC
Entity Type:Organization
Organization Name:SURREY PLACE OF LACANTO LLC
Other - Org Name:DIAMOND RIDGE HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-386-2831
Mailing Address - Street 1:2123 CENTRE POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4930
Mailing Address - Country:US
Mailing Address - Phone:850-386-2831
Mailing Address - Fax:850-386-2016
Practice Address - Street 1:2730 W MARC KNIGHTON CT
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8334
Practice Address - Country:US
Practice Address - Phone:352-746-9500
Practice Address - Fax:352-746-9666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025626900Medicaid
4484980001Medicare NSC
FL025626900Medicaid