Provider Demographics
NPI:1336221019
Name:SOUTH LAKE HOSPITAL, INC.
Entity Type:Organization
Organization Name:SOUTH LAKE HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:TYNES
Authorized Official - Last Name:NAPIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-650-3763
Mailing Address - Street 1:1414 KUHL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:321-841-5111
Mailing Address - Fax:407-650-3785
Practice Address - Street 1:1900 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1947
Practice Address - Country:US
Practice Address - Phone:352-394-4071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4180275N00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL314OtherBCBS
FL020022100Medicaid
FL010108700Medicaid
FL314OtherBCBS
FL10U051Medicare ID - Type Unspecified