MEDICARE: SHANDS AT LAKE SHORE INC

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	261QM1300X	Multi-Specialty Clinic/Center
2	261Q00000X	Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CK8077	OTHER	FL	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871692475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANDS AT LAKE SHORE INC

Provider Business Mailing Address
First Line	:	720 SW 2ND AVE
Second Line	:	SUITE 360C
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-6271
Country	:	US
Telephone Number	:	352-733-0060
Fax Number	:	352-733-0069

Provider Business Practice Location Address
First Line	:	755 SW STATE ROAD 47
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-0453
Country	:	US
Telephone Number	:	386-755-7788
Fax Number	:	352-733-0069

Authorized Official
Title or Position	:	SR. VICE PRESIDENT & COO
Name	:	MS. JODI MANSFIELD
Credential	:
Telephone Number	:	352-265-0440

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	05/07/2008

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Directions to “SHANDS AT LAKE SHORE INC ” Practice Location

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