Healthcare Provider Details

I. General information

NPI: 1982905097
Provider Name (Legal Business Name): WELLSPRING ASSISTED LIVING FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37815 15TH AVE
ZEPHYRHILLS FL
33542-3217
US

IV. Provider business mailing address

PO BOX 280339
TAMPA FL
33682-0339
US

V. Phone/Fax

Practice location:
  • Phone: 813-715-1000
  • Fax: 813-425-6925
Mailing address:
  • Phone: 813-715-1000
  • Fax: 813-425-6925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL10854
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL10854
License Number StateFL

VIII. Authorized Official

Name: MR. JOSEPH WILFRED JOSEPH
Title or Position: MGR/ADMINISTRATOR
Credential:
Phone: 813-715-1000