Basic Information
| Provider Information | |||||||||
| NPI: | 1023616943 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WICKSHIRE PORT ORANGE OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 OLD HICKORY BLVD | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159420240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 DUNLAWTON AVE | ||||||||
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| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321274755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867611055 | ||||||||
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| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | O'KEEFE | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6159420240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.