Provider Demographics
NPI:1457306797
Name:SANDLAKE LIVING ASSISTING HOME
Entity Type:Organization
Organization Name:SANDLAKE LIVING ASSISTING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHAWNDA
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-779-6878
Mailing Address - Street 1:7798 ORTEGA BLUFF PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-8209
Mailing Address - Country:US
Mailing Address - Phone:904-779-6878
Mailing Address - Fax:904-772-7733
Practice Address - Street 1:7798 ORTEGA BLUFF PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-8209
Practice Address - Country:US
Practice Address - Phone:904-779-6878
Practice Address - Fax:904-772-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness