CCRC - Lake Port Square, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

CCRC - LAKE PORT SQUARE, LLC

Practice address

701 Lake Port Blvd
Leesburg, FL 34748-7674

Phone

(352) 728-3366

NPI assigned

Jun 16, 2014

Organization subpart

No

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

Authorized official

Name

Tristan Mohadeo

Title

Administrator

Phone

(352) 728-8525

Specialties & licenses 1

Addresses

Other names 1

• Lake Port Square Health Center Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Skilled nursing facility certification: CCN 105705

Legal name

CCRC - LAKE PORT SQUARE LLC

Doing business as

LAKE PORT SQUARE HEALTH CENTER

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Aug 27, 1990

Last certification

Feb 13, 2025

Beds

80

Ownership / control type

Limited Liability Corporation

Multi-facility organization

Health Peak/ Janus Living

Organization structure

LLCProprietary

Incorporated

May 2, 2014 in DE

Enrollment address

701 Lake Port Blvd
Leesburg, FL 34748-7674

Nursing home name

LAKE PORT SQUARE HEALTH CENTER

Affiliated entity

HEALTHPEAK PROPERTIES, INC.

Listed as

Lake Port Square Health CenterCCN 105705

Overall star rating

3 of 5

Health inspections

3 of 5

Staffing

3 of 5

Quality measures

3 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Aug 27, 1990

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

8074.9 residents per day on average

Chain

Healthpeak Properties, Inc.15 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

CCRC - Lake Port Square LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Lake Harris Health Systems LLC

  • Skilled Nursing Facility
  • Leesburg, FL
  • NPI 1740295476
  NPD tax ID

Networks

• Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Maximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
• Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

All disclosed owners & managing parties 27

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

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Axel E. Martinez Irizarry, M.D.

  • Family Medicine Physician
  • Ocala, FL
  • NPI 1689860421

  Adp of the SNF, Operational/Managerial Control

  CMS ownership
• Andres Felipe Vallejo Agudelo, M.D.

  • Internal Medicine Physician
  • Lake Mary, FL
  • NPI 1871960997

  Adp of the SNF, Operational/Managerial Control

  CMS ownership

Facilities with the same owner 63

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

• Arlington of Naples LLC

  • Skilled Nursing Facility
  • Naples, FL
  • NPI 1326771015

  Life Care Services LLC

  CMS ownership
• CCRC - Regency Oaks, LLC

  • Skilled Nursing Facility
  • Clearwater, FL
  • NPI 1164836425

  CCRC Propco Ventures, LLC, HCP Ma3, LP, HCP Partners LP, HCP S-H 2014 Member LLC, HCP Ventures II Partner LLC, HCP/LS 2011 Reit, LLC, Healthpeak Op LLC, Healthpeak Properties Inc, Janus Living TRS LLC, Janus Living, Inc., Janus Member, LLC, Lif

  CMS ownership
• CCRC - South Port Square, LLC

  • Skilled Nursing Facility
  • Port Charlotte, FL
  • NPI 1376957803

  CCRC Opco Ventures, LLC, HCP S-H 2014 Member LLC, Healthpeak Op LLC, Healthpeak Properties Inc, Life Care Services LLC

  CMS ownership
• CCRC Opco - Bradenton, LLC

  • Skilled Nursing Facility
  • Bradenton, FL
  • NPI 1417361858

  CCRC Propco Ventures, LLC, HCP Ma3, LP, HCP Partners LP, HCP S-H 2014 Member LLC, HCP Ventures II Partner LLC, HCP/LS 2011 Reit, LLC, Healthpeak Properties Inc, Janus Living TRS LLC, Janus Living, Inc., Janus Member, LLC, Life Care Services LLC

  CMS ownership
• CCRC Opco - Cypress Village, LLC

  • Skilled Nursing Facility
  • Jacksonville, FL
  • NPI 1790199057

  CCRC Propco Ventures, LLC, HCP Ma3, LP, HCP Partners LP, HCP S-H 2014 Member LLC, HCP Ventures II Partner LLC, HCP/LS 2011 Reit, LLC, Healthpeak Op LLC, Healthpeak Properties Inc, Janus Living, Inc., Janus Member, LLC, Life Care Services LLC, S

  CMS ownership
• CCRC Opco - Sun City Center, LLC

  • Skilled Nursing Facility
  • Sun City Center, FL
  • NPI 1699189126

  HCP Ma3, LP, HCP Partners LP, Life Care Services LLC

  CMS ownership
• CCRC Opco-Freedom Square, LLC

  • Skilled Nursing Facility
  • Seminole, FL
  • NPI 1780098202

  Life Care Services LLC

  CMS ownership
• CCRC-Freedom Pointe at the Villages, LLC

  • Skilled Nursing Facility
  • Lady Lake, FL
  • NPI 1457587818

  CCRC Propco Ventures, LLC, HCP Ma3, LP, HCP Partners LP, HCP S-H 2014 Member LLC, HCP Ventures II Partner LLC, HCP/LS 2011 Reit, LLC, Healthpeak Op LLC, Healthpeak Properties Inc, Janus Living TRS LLC, Janus Living, Inc., Janus Member, LLC, Lif

  CMS ownership
• Pelican Bay Retirement Services Inc

  • Skilled Nursing Facility
  • Naples, FL
  • NPI 1083663991

  Life Care Services LLC

  CMS ownership
• Brandon Wilde LLC

  • Skilled Nursing Facility
  • Evans, GA
  • NPI 1780450924

  Life Care Services LLC

  CMS ownership
• Burcham Hills Retirement Center II

  • Skilled Nursing Facility
  • East Lansing, MI
  • NPI 1659344844

  Life Care Services LLC

  CMS ownership
• Carillon, Inc.

  • Skilled Nursing Facility
  • Lubbock, TX
  • NPI 1275524027

  Life Care Services LLC

  CMS ownership

Affiliated clinicians 4

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

• Yanira Isbet Lara, M.D.

  • Family Medicine Physician
  • Bushnell, FL
  • NPI 1306108022

  Nursing home

  Care Compare affiliation
• Sharon Lynn Preloznik

  • Family Nurse Practitioner
  • Jacksonville, FL
  • NPI 1134988330

  Nursing home

  Care Compare affiliation
• Roger C Roque, MD

  • Family Medicine Physician
  • Eustis, FL
  • NPI 1437156916

  Nursing home

  Care Compare affiliation
• Manuel Eduardo Abraham Gonzalez, M.D.

  • General Practice Physician
  • San Juan, PR
  • NPI 1811297534

  Nursing home

  Care Compare affiliation

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

{
    "created_epoch": "1402876800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1768780800000",
    "number": "1073927331",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1920 MAIN ST STE 1200",
            "city": "IRVINE",
            "state": "CA",
            "postal_code": "926147230",
            "telephone_number": "949-407-0700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 LAKE PORT BLVD",
            "city": "LEESBURG",
            "state": "FL",
            "postal_code": "347487674",
            "telephone_number": "352-728-3366"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CCRC - LAKE PORT SQUARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-06-16",
        "last_updated": "2026-01-19",
        "certification_date": "2026-01-19",
        "status": "A",
        "authorized_official_last_name": "MOHADEO",
        "authorized_official_first_name": "TRISTAN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "352-728-8525"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Other",
            "address_1": "8615 W 108th Pl",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101604",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Lake Port Square Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Michael A Cary, PT
• Montserrat Casado-Kehoe, LMFT
• Carolyn Casler
• Azenith Casupang, OTR/L
• Jennifer Caswell
• Cdpa, Inc
• Maria Ceballos, DPT
• Patricia Rose Cecil, NP
• Centerwell Senior Primary Care (FL) Inc.
• Central Florida Associated Primary Care Physicians, PA

• All providers in Leesburg, FL
• Skilled Nursing Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.