MEDICARE: SKYCREST PLACE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1194463000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYCREST PLACE LLC

Provider Business Mailing Address
First Line	:	106 OAK AVE
Second Line	:
City	:	SAFETY HARBOR
State	:	FL
Zip	:	34695-3708
Country	:	US
Telephone Number	:	727-254-1196
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 CLEVELAND ST
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33765-3016
Country	:	US
Telephone Number	:	727-254-1196
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	STEPHEN WEIK
Credential	:
Telephone Number	:	727-254-1196

Provider Enumeration Date	:	05/22/2022
Last Update Date	:	05/22/2022

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Directions to “SKYCREST PLACE LLC ” Practice Location

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