Provider Demographics
NPI:1902450604
Name:LAKE ISLAND HEALTHCARE, INC.
Entity Type:Organization
Organization Name:LAKE ISLAND HEALTHCARE, INC.
Other - Org Name:WILLOW TREE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:2050 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-2407
Mailing Address - Country:US
Mailing Address - Phone:970-874-9773
Mailing Address - Fax:
Practice Address - Street 1:2050 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2407
Practice Address - Country:US
Practice Address - Phone:970-874-9773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility