Provider Demographics
NPI:1740514496
Name:LAKE BENNETT INC
Entity type:Organization
Organization Name:LAKE BENNETT INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-258-0316
Mailing Address - Street 1:1091 KELTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3162
Mailing Address - Country:US
Mailing Address - Phone:850-258-0316
Mailing Address - Fax:850-392-0000
Practice Address - Street 1:1091 KELTON AVE
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3162
Practice Address - Country:US
Practice Address - Phone:850-258-0316
Practice Address - Fax:850-392-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105967Medicare Oscar/Certification