Provider Demographics
NPI:1033157607
Name:LIFESPACE COMMUNITIES INC
Entity Type:Organization
Organization Name:LIFESPACE COMMUNITIES INC
Other - Org Name:THE WATERFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-288-5805
Mailing Address - Street 1:601 UNIVERSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JUNO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-2444
Mailing Address - Country:US
Mailing Address - Phone:561-627-3800
Mailing Address - Fax:561-694-0242
Practice Address - Street 1:601 UNIVERSE BLVD
Practice Address - Street 2:
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-2444
Practice Address - Country:US
Practice Address - Phone:561-627-3800
Practice Address - Fax:561-694-0242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPACE COMMUNITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21181096251E00000X
FLSNF1587096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL22OtherBC/BS
FL020661000Medicaid
105404Medicare Oscar/Certification