Provider Demographics
NPI:1871212357
Name:BELLA VIDA AT LAKE FOREST, LLC
Entity type:Organization
Organization Name:BELLA VIDA AT LAKE FOREST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-431-5159
Mailing Address - Street 1:7901 4TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4399
Mailing Address - Country:US
Mailing Address - Phone:352-269-3779
Mailing Address - Fax:321-256-5193
Practice Address - Street 1:4055 LAKE FOREST ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-5211
Practice Address - Country:US
Practice Address - Phone:352-269-3779
Practice Address - Fax:321-256-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility