Provider Demographics
NPI:1609877976
Name:SOUTH LAKE HOSPITAL, INC.
Entity type:Organization
Organization Name:SOUTH LAKE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-241-7138
Mailing Address - Street 1:1920 DON WICKHAM DRIVE
Mailing Address - Street 2:STE 110
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711
Mailing Address - Country:US
Mailing Address - Phone:352-241-7138
Mailing Address - Fax:352-241-7248
Practice Address - Street 1:1120 CITRUS TOWER BLVD
Practice Address - Street 2:STE 110
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1909
Practice Address - Country:US
Practice Address - Phone:352-241-7138
Practice Address - Fax:352-241-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHA210740962251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650128100Medicaid
FLJ5YOtherBCBS
FLJ5YOtherBCBS