Provider Demographics
NPI:1578500443
Name:LIFESPACE COMMUNITIES INC
Entity Type:Organization
Organization Name:LIFESPACE COMMUNITIES INC
Other - Org Name:VILLAGE ON THE GREEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-288-5805
Mailing Address - Street 1:515 VILLAGE PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-6041
Mailing Address - Country:US
Mailing Address - Phone:407-682-0230
Mailing Address - Fax:407-682-3893
Practice Address - Street 1:515 VILLAGE PL
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-6041
Practice Address - Country:US
Practice Address - Phone:407-682-0230
Practice Address - Fax:407-682-3893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPACE COMMUNITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21234096251E00000X
FLSNF1579096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherFEDERAL TAX ID
FL105556Medicare Oscar/Certification