Provider Demographics
NPI:1629052014
Name:LIFETIDES HOME, INC.
Entity Type:Organization
Organization Name:LIFETIDES HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILENGE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:727-804-4500
Mailing Address - Street 1:3438 E LAKE RD
Mailing Address - Street 2:SUITE 14, PMB 650
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2400
Mailing Address - Country:US
Mailing Address - Phone:727-804-4500
Mailing Address - Fax:727-943-7505
Practice Address - Street 1:3133 LAS OLAS DR
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-2914
Practice Address - Country:US
Practice Address - Phone:727-804-4500
Practice Address - Fax:727-943-7505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9832310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility