Provider Demographics
NPI:1962849778
Name:BEAR LAKE RETIREMENT HOME
Entity Type:Organization
Organization Name:BEAR LAKE RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-296-7075
Mailing Address - Street 1:1525 BEAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6736
Mailing Address - Country:US
Mailing Address - Phone:407-296-7075
Mailing Address - Fax:321-445-4740
Practice Address - Street 1:1525 BEAR LAKE RD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-6736
Practice Address - Country:US
Practice Address - Phone:407-296-7075
Practice Address - Fax:321-445-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8413310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140986700Medicaid