Provider Demographics
NPI:1750365706
Name:LAKE CITY MGT LLC
Entity type:Organization
Organization Name:LAKE CITY MGT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-956-6956
Mailing Address - Street 1:1270 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6684
Mailing Address - Country:US
Mailing Address - Phone:386-752-7900
Mailing Address - Fax:386-752-8556
Practice Address - Street 1:1270 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6684
Practice Address - Country:US
Practice Address - Phone:386-752-7900
Practice Address - Fax:386-752-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF15510961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026162900Medicaid
FL026162900Medicaid
FL5089640001Medicare NSC