Organization
STILL WATERS OF LAKE CITY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THREASA HYSELL R.N. (EXECUTIVE DIRECTOR)
(386) 755-6560
Entity
Organization
Contact information
Practice address
507 NW HALL OF FAME DR, LAKE CITY, FL 32055-4835
(386) 755-6560
(386) 628-5018
Mailing address
507 NW HALL OF FAME DR, LAKE CITY, FL 32055-4835
(386) 755-6560
(386) 628-5018
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
AL9472
FL
311500000X
Alzheimer Center (Dementia Center)
AL9472
FL
311ZA0620X
Adult Care Home Facility
AL9472
FL
385H00000X
Respite Care
AL9472
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
682130800
MEDICAID WAIVER
FL
Enumeration date
11/15/2012
Last updated
11/15/2012
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