Provider Demographics
NPI:1700182235
Name:LAKE WALES HEALTHCARE LLC
Entity Type:Organization
Organization Name:LAKE WALES HEALTHCARE LLC
Other - Org Name:GRACE HEALTHCARE OF LAKE WALES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLARK DANKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:423-308-1845
Mailing Address - Street 1:730 N SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3208
Mailing Address - Country:US
Mailing Address - Phone:863-676-1512
Mailing Address - Fax:
Practice Address - Street 1:730 N SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3208
Practice Address - Country:US
Practice Address - Phone:863-676-1512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF12760961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031934100Medicaid
FL031934100Medicaid