Healthcare Provider Details

I. General information

NPI: 1952708752
Provider Name (Legal Business Name): SPRING PINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 MILL SLOUGH RD
KISSIMMEE FL
34744-2620
US

IV. Provider business mailing address

1324 MILL SLOUGH RD
KISSIMMEE FL
34744-2620
US

V. Phone/Fax

Practice location:
  • Phone: 321-246-7486
  • Fax: 407-870-7691
Mailing address:
  • Phone: 321-246-7486
  • Fax: 407-870-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number12580
License Number StateFL

VIII. Authorized Official

Name: MS. VESNA SAKALAS
Title or Position: ADMINISTRATOR
Credential:
Phone: 321-246-7484