Healthcare Provider Details

I. General information

NPI: 1104160027
Provider Name (Legal Business Name): STILL WATERS OF LAKE CITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 NW HALL OF FAME DR
LAKE CITY FL
32055-4835
US

IV. Provider business mailing address

507 NW HALL OF FAME DR
LAKE CITY FL
32055-4835
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-6560
  • Fax: 386-628-5018
Mailing address:
  • Phone: 386-755-6560
  • Fax: 386-628-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9472
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL9472
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAL9472
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberAL9472
License Number StateFL

VIII. Authorized Official

Name: THREASA HYSELL
Title or Position: EXECUTIVE DIRECTOR
Credential: R.N.
Phone: 386-755-6560