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General NPI Number Information
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NPI Number | 1902452964
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Entity Type | Organization
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Legal Business Name | MARKET STREET EAST LAKE SL, LLC
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Dates
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Enumeration Date | 08/15/2019
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Last Update Date | 08/15/2019
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Provider Practice Location Address
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Address Line | 833 E LAKE RD N
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City | TARPON SPRINGS
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State | FL
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Zip | 34688-6308
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Country | US
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Telephone | 727-202-9314
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Fax |
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Provider Business Mailing Address
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Address Line | 445 24TH ST STE 300
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City | VERO BEACH
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State | FL
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Zip | 32960-7502
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Country | US
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Telephone | 772-539-4560
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Fax | 772-257-6934
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Authorized Official
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Title or Position | MANAGER AND CFO
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Name | JOAN WILLIAMS
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Credential |
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Telephone | 772-539-4560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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