Organization
CCRC - LAKE PORT SQUARE, LLC
Active
Other names
Lake Port Square Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
TRISTAN MOHADEO (ADMINISTRATOR)
(352) 728-8525
Entity
Organization
Contact information
Practice address
701 LAKE PORT BLVD, LEESBURG, FL 34748-7674
(352) 728-3366
Mailing address
1920 MAIN ST STE 1200, IRVINE, CA 92614-7230
(949) 407-0700
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Enumeration date
06/16/2014
Last updated
01/19/2026
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