Healthcare Provider Details

I. General information

NPI: 1871692475
Provider Name (Legal Business Name): SHANDS AT LAKE SHORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SW STATE ROAD 47
LAKE CITY FL
32025-0453
US

IV. Provider business mailing address

720 SW 2ND AVE SUITE 360C
GAINESVILLE FL
32601-6271
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-7788
  • Fax: 352-733-0069
Mailing address:
  • Phone: 352-733-0060
  • Fax: 352-733-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JODI MANSFIELD
Title or Position: SR. VICE PRESIDENT & COO
Credential:
Phone: 352-265-0440