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General NPI Number Information
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NPI Number | 1104160027
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Entity Type | Organization
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Legal Business Name | STILL WATERS OF LAKE CITY, INC.
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 507 NW HALL OF FAME DR
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City | LAKE CITY
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State | FL
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Zip | 32055-4835
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Country | US
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Telephone | 386-755-6560
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Fax | 386-628-5018
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Provider Business Mailing Address
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Address Line | 507 NW HALL OF FAME DR
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City | LAKE CITY
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State | FL
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Zip | 32055-4835
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Country | US
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Telephone | 386-755-6560
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Fax | 386-628-5018
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | THREASA HYSELL
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Credential | R.N.
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Telephone | 386-755-6560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | AL9472
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AL9472
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | AL9472
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL9472
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License Number State | FL
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