Healthcare Provider Details

I. General information

NPI: 1932100229
Provider Name (Legal Business Name): CYPRESS COVE CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/07/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SE DR. MARTIN LUTHER KING JR. AVENUE
CRYSTAL RIVER FL
34429-4855
US

IV. Provider business mailing address

700 SE DR. MARTIN LUTHER KING AVE
CRYSTAL RIVER FL
34429-4855
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-8832
  • Fax: 352-795-0490
Mailing address:
  • Phone: 352-795-8832
  • Fax: 352-795-0490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberSNF1115096
License Number StateFL

VIII. Authorized Official

Name: SCOTT FISHER
Title or Position: CFO
Credential:
Phone: 352-417-0360