Provider Demographics
NPI:1336587708
Name:GRACE MANOR AT LAKE MORTON, LLC
Entity Type:Organization
Organization Name:GRACE MANOR AT LAKE MORTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. ADMINISTRATOR
Authorized Official - Prefix:MS
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 1:505 ARIANA AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-4139
Mailing Address - Country:US
Mailing Address - Phone:863-226-0358
Mailing Address - Fax:863-875-9489
Practice Address - Street 1:610 E LIME STREET
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801
Practice Address - Country:US
Practice Address - Phone:863-937-9114
Practice Address - Fax:863-937-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)