NPIMap

Organization Active NPI

Lake City Nursing and Rehabilitation Center, LLC

  • Skilled Nursing Facility
  • Lake City, GA
National Provider Identifier
1053420729
Registry record updated Dec 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
10311849 Issued in GA
Legal business name
LAKE CITY NURSING AND REHABILITATION CENTER, LLC
Practice address
2055 Rex Rd
Lake City, GA 30260-3944
Phone
(404) 361-5114
Fax
(404) 363-6366
NPI assigned
Aug 29, 2006
Last updated
Dec 8, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 8, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Norbert A Bennett
Title
Co-Ceo
Phone
(716) 662-4955

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 10311849 GA Primary

Addresses

Primary practice location

2055 Rex Rd
Lake City, GA 30260-3944

Mailing address

PO Box 428
Orchard Park, NY 14127-0428
Phone (716) 662-4955

Other identifiers 1

IdentifierTypeStateIssuer
00141699AMedicaidGA

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL ENDPOINT Other The White Stone Group d/b/a Vyne Medical

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051215000853 GA Part A Provider - Skilled Nursing Facility 3375564404 Practice locations: Lake City, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053420729. Details of each certification follow.

Skilled nursing facility certification: CCN 115535

Legal name
LAKE CITY NURSING AND REHABILITATION CENTER, LLC
Doing business as
LAKE CITY NURSING AND REHABILITATION CENTER, LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 4, 1993
Last certification
Jul 18, 2024
Beds
242
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Empire Care Centers LLC
Organization structure
LLCProprietary
Incorporated
Jan 1, 2006 in GA
Enrollment address
2055 Rex Rd
Lake City, GA 30260-3944
Nursing home name
LAKE CITY CENTER FOR NURSING AND HEALING LLC
Affiliated entity
NORBERT BENNETT & DONALD DENZ

Care Compare: Nursing home

Medicare Care Compare
Listed as
Lake City Center for Nursing and Healing LLCCCN 115535 · All quality measures
Overall star rating
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
1 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jan 4, 1993
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
242211.0 residents per day on average
Chain
Norbert Bennett & Donald Denz2 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Donad T Denz Irrv TR Organization, Buffalo, NY 5% Or Greater Indirect Ownership Interest May 23, 2008 6%
Norbert a Bennett Individual 5% Or Greater Indirect Ownership InterestAuthorized Official Jan 1, 2006 32.45%
Donald T Denz Individual 5% Or Greater Indirect Ownership InterestAuthorized Official Jan 1, 2006 44%
Norbert a Bennett Irrv TR Fbo Grandchildren Organization, Holland, NY 5% Or Greater Indirect Ownership Interest May 23, 2008 17.55%
Paula a Sarju Individual W-2 Managing EmployeeExecutive Director Jun 7, 2021 100%
Norbert a Bennett Irrv TR Fbo Children Organization, Holland, NY 5% Or Greater Indirect Ownership Interest May 23, 2008 17.55%
Renee Klawon Individual OtherIndependent Contractor Aug 14, 2020
D&N, LLC Organization, Orchard Park, NY LLC 5% Or Greater Direct Ownership Interest Jan 1, 2006 50%
DTD HC LLC Organization, Orchard Park, NY LLC 5% Or Greater Direct Ownership Interest Jan 1, 2006 50%

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701993600000",
    "number": "1053420729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 428",
            "city": "ORCHARD PARK",
            "state": "NY",
            "postal_code": "141270428",
            "telephone_number": "716-662-4955",
            "fax_number": "716-667-9230"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2055 REX RD",
            "city": "LAKE CITY",
            "state": "GA",
            "postal_code": "302603944",
            "telephone_number": "404-361-5114",
            "fax_number": "404-363-6366"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE CITY NURSING AND REHABILITATION CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-29",
        "last_updated": "2023-12-08",
        "certification_date": "2023-12-08",
        "status": "A",
        "authorized_official_last_name": "BENNETT",
        "authorized_official_first_name": "NORBERT",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CO-CEO",
        "authorized_official_telephone_number": "716-662-4955",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "GA",
            "license": "10311849",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00141699A",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "ENDPOINT",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.17.8788.1",
            "affiliationName": "The White Stone Group d/b/a Vyne Medical",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 Ashford Ctr N Ste 300",
            "city": "Atlanta",
            "state": "GA",
            "country_code": "US",
            "postal_code": "303384863",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Lake City, GA

Sources for this page

Verify at the official NPI Registry.