Organization
WELLSPRINGS RESIDENCE LLC
Active
Other names
Black Ring Capital Investments LLC
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SUSAN I. KORNEGAY JD, MBA, BSN, RN (AUTHORIZED MANAGING MEMBER)
(407) 951-0268
Entity
Organization
Contact information
Practice address
700 E WELCH RD, APOPKA, FL 32712-2921
(407) 880-8020
(407) 264-8660
Mailing address
700 E WELCH RD, APOPKA, FL 32712-2921
(407) 880-8020
(407) 264-8660
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
251E00000X
Home Health Agency
—
—
251J00000X
Nursing Care Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
253Z00000X
In Home Supportive Care Agency
—
—
261QA0600X
Adult Day Care Clinic/Center
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
310400000X
Assisted Living Facility
—
—
311500000X
Alzheimer Center (Dementia Center)
—
—
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
—
—
314000000X
Skilled Nursing Facility
—
—
385H00000X
Respite Care
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100011400
—
FL
01
—
11968599
AGENCY FOR HEALTHCARE ADMINISTRATION (AHCA)
FL
01
—
96EQ6
SAM CAGE CODE
—
01
—
GJHJCRUH32H5
SAM UNIQUE ENTITY ID
—
Enumeration date
07/25/2018
Last updated
10/06/2022
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