Provider Demographics
NPI:1245857135
Name:HIDDEN LAKE SNF OPCO, LLC
Entity type:Organization
Organization Name:HIDDEN LAKE SNF OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-259-9800
Mailing Address - Street 1:20 3RD ST SW STE 308
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-2969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11400 HIDDEN LAKE DR
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-7409
Practice Address - Country:US
Practice Address - Phone:816-737-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103256202Medicaid