Healthcare Provider Details

I. General information

NPI: 1457306797
Provider Name (Legal Business Name): SANDLAKE LIVING ASSISTING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7798 ORTEGA BLUFF PKWY
JACKSONVILLE FL
32244-8209
US

IV. Provider business mailing address

7798 ORTEGA BLUFF PKWY
JACKSONVILLE FL
32244-8209
US

V. Phone/Fax

Practice location:
  • Phone: 904-779-6878
  • Fax: 904-772-7733
Mailing address:
  • Phone: 904-779-6878
  • Fax: 904-772-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. LASHAWNDA KIM LEWIS
Title or Position: CEO
Credential:
Phone: 904-779-6878