Provider Demographics
NPI:1619572054
Name:SEDGEWOOD MANOR HEALTHCARE CENTER LLC
Entity Type:Organization
Organization Name:SEDGEWOOD MANOR HEALTHCARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SAVITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-226-0358
Mailing Address - Street 1:1833 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2653
Mailing Address - Country:US
Mailing Address - Phone:863-226-0358
Mailing Address - Fax:
Practice Address - Street 1:1645 RIDGE RD
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:SC
Practice Address - Zip Code:29061-8432
Practice Address - Country:US
Practice Address - Phone:803-776-3873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRC1532Medicaid