Healthcare Provider Details

I. General information

NPI: 1932173010
Provider Name (Legal Business Name): LIFESTYLES 1 HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 110TH AVE
SEMINOLE FL
33778-3711
US

IV. Provider business mailing address

11300 110TH AVE
SEMINOLE FL
33778-3711
US

V. Phone/Fax

Practice location:
  • Phone: 727-391-9986
  • Fax: 727-456-5555
Mailing address:
  • Phone: 727-391-9986
  • Fax: 727-456-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1614096
License Number StateFL

VIII. Authorized Official

Name: MR. WILLIAM C KELSEY
Title or Position: MANAGER
Credential:
Phone: 727-391-9986