Provider Demographics
NPI:1568764371
Name:SANDY LEMKE SUPPORTED LIVING SERVICES, INC.
Entity Type:Organization
Organization Name:SANDY LEMKE SUPPORTED LIVING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-823-9160
Mailing Address - Street 1:PO BOX 16521
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-6521
Mailing Address - Country:US
Mailing Address - Phone:727-823-9160
Mailing Address - Fax:727-824-8841
Practice Address - Street 1:735 38TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-3837
Practice Address - Country:US
Practice Address - Phone:727-823-9160
Practice Address - Fax:727-824-8841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL672827896OtherMEDICAID DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER NUMBER
FL672827801OtherMEDICAID DEVELOPMENTAL DISABILITIES FAMILY AND SUPPORTED LIVING WAIVER