=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285502963
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BANKWELL RESIDENTIAL COMMUNITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2025
-----------------------------------------------------
Last Update Date | 10/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 64TH AVE S
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33705-5924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-906-1034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 64TH AVE S
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33705-5924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-906-1034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CRYSTAL M WELLS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 727-906-1034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------