Provider Demographics
NPI:1912079831
Name:1091 KELTON INC
Entity Type:Organization
Organization Name:1091 KELTON INC
Other - Org Name:LAKE BENNETT HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-523-0300
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:407-523-0300
Mailing Address - Fax:
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:407-523-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105967Medicare ID - Type Unspecified