Provider Demographics
NPI:1972505949
Name:LAKEWOOD NURSING CENTER INC
Entity Type:Organization
Organization Name:LAKEWOOD NURSING CENTER INC
Other - Org Name:PUTNAM COUNCIL ON AGING, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-993-4000
Mailing Address - Street 1:100 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-2620
Mailing Address - Country:US
Mailing Address - Phone:386-698-2222
Mailing Address - Fax:386-698-2717
Practice Address - Street 1:100 N LAKE ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2620
Practice Address - Country:US
Practice Address - Phone:386-698-2222
Practice Address - Fax:386-698-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031214200Medicaid
FL105808Medicare Oscar/Certification