Provider Demographics
NPI:1750784229
Name:LAKESHORE MANOR, LLC
Entity type:Organization
Organization Name:LAKESHORE MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANALILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-989-5449
Mailing Address - Street 1:960 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2932
Mailing Address - Country:US
Mailing Address - Phone:352-989-5449
Mailing Address - Fax:
Practice Address - Street 1:960 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2932
Practice Address - Country:US
Practice Address - Phone:352-989-5449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12554310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility