Healthcare Provider Details

I. General information

NPI: 1750989687
Provider Name (Legal Business Name): WICKSHIRE COUNTRYSIDE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3141 N MCMULLEN BOOTH RD
CLEARWATER FL
33761-2035
US

IV. Provider business mailing address

750 OLD HICKORY BLVD
BRENTWOOD TN
37027-4528
US

V. Phone/Fax

Practice location:
  • Phone: 727-723-7110
  • Fax:
Mailing address:
  • Phone: 615-942-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: DAN O'KEEFE
Title or Position: CEO
Credential:
Phone: 615-942-0240