Provider Demographics
NPI:1275010969
Name:WELLSPRINGS RESIDENCE LLC
Entity Type:Organization
Organization Name:WELLSPRINGS RESIDENCE LLC
Other - Org Name:BLACK RING CAPITAL INVESTMENTS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUTHORIZED MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MBA, BSN, RN
Authorized Official - Phone:407-951-0268
Mailing Address - Street 1:700 E WELCH RD
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2921
Mailing Address - Country:US
Mailing Address - Phone:407-880-8020
Mailing Address - Fax:407-264-8660
Practice Address - Street 1:700 E WELCH RD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2921
Practice Address - Country:US
Practice Address - Phone:407-880-8020
Practice Address - Fax:407-264-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
96EQ6OtherSAM CAGE CODE
FL100011400Medicaid
GJHJCRUH32H5OtherSAM UNIQUE ENTITY ID
FL11968599OtherAGENCY FOR HEALTHCARE ADMINISTRATION (AHCA)