Provider Demographics
NPI:1336903400
Name:1031CF LAKE CITY MT LLC
Entity Type:Organization
Organization Name:1031CF LAKE CITY MT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-533-1031
Mailing Address - Street 1:213 NW GLEASON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-5846
Mailing Address - Country:US
Mailing Address - Phone:386-344-6985
Mailing Address - Fax:386-438-5272
Practice Address - Street 1:213 NW GLEASON DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-5846
Practice Address - Country:US
Practice Address - Phone:386-344-6985
Practice Address - Fax:386-438-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility