Basic Information
| Provider Information | |||||||||
| NPI: | 1639743552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WICKSHIRE FORT MYERS OPCO LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 750 OLD HICKORY BLVD | ||||||||
| Address2: | BUILDING ONE SUITE 125 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159420240 | ||||||||
| FaxNumber: | 6158067680 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 HANCOCK BRIDGE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392175900 | ||||||||
| FaxNumber: | 2392175960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2021 | ||||||||
| LastUpdateDate: | 05/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'KEEFE | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6159420240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | JD | ||||||||
| NPICertificationDate: | 05/15/2021 | ||||||||
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.