Provider Demographics
NPI:1649267212
Name:CONWAY LAKES NC, LLC
Entity type:Organization
Organization Name:CONWAY LAKES NC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AS SOLE MEMBER OF SBK CAPITAL LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-250-1846
Mailing Address - Street 1:5201 CURRY FORD RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-8741
Mailing Address - Country:US
Mailing Address - Phone:407-384-8838
Mailing Address - Fax:407-384-7936
Practice Address - Street 1:5201 CURRY FORD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-8741
Practice Address - Country:US
Practice Address - Phone:407-384-8838
Practice Address - Fax:407-384-7936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF11020963314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
V673P-5339OtherVA
FL026451200Medicaid
105754Medicare ID - Type Unspecified