Provider Demographics
NPI:1457726838
Name:GV LAKELAND, LLC
Entity Type:Organization
Organization Name:GV LAKELAND, LLC
Other - Org Name:GRAND VILLA OF LAKELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:13770 58TH ST N
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3759
Mailing Address - Country:US
Mailing Address - Phone:727-726-3980
Mailing Address - Fax:727-726-5345
Practice Address - Street 1:2111 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2905
Practice Address - Country:US
Practice Address - Phone:836-688-1126
Practice Address - Fax:863-683-3326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 6107310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility