Provider Demographics
NPI:1225378730
Name:TIFFANY LAKE CARE CENTERS, INC
Entity Type:Organization
Organization Name:TIFFANY LAKE CARE CENTERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-689-2030
Mailing Address - Street 1:402 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6740
Mailing Address - Country:US
Mailing Address - Phone:386-423-1120
Mailing Address - Fax:
Practice Address - Street 1:402 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6740
Practice Address - Country:US
Practice Address - Phone:386-423-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8788310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility