Healthcare Provider Details

I. General information

NPI: 1164103883
Provider Name (Legal Business Name): PCP LAKESHORE DRIVE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 LAKESHORE DR
TALLAHASSEE FL
32312-2104
US

IV. Provider business mailing address

2573 BARRINGTON CIR
TALLAHASSEE FL
32308-6805
US

V. Phone/Fax

Practice location:
  • Phone: 850-616-6253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: SETH WALKER
Title or Position: CFO, SRIM
Credential:
Phone: 850-583-7990