Provider Demographics
NPI:1619767340
Name:LAKE SMITH SHORES, LLC
Entity type:Organization
Organization Name:LAKE SMITH SHORES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-205-5515
Mailing Address - Street 1:16624 LAKE SMITH RD
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-8838
Mailing Address - Country:US
Mailing Address - Phone:407-205-5515
Mailing Address - Fax:
Practice Address - Street 1:16624 LAKE SMITH RD
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8838
Practice Address - Country:US
Practice Address - Phone:407-205-5515
Practice Address - Fax:352-669-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility