Provider Demographics
NPI:1932100229
Name:CYPRESS COVE CARE CENTER, LLC
Entity Type:Organization
Organization Name:CYPRESS COVE CARE CENTER, LLC
Other - Org Name:CYPRESS COVE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-417-0360
Mailing Address - Street 1:700 SE DR. MARTIN LUTHER KING AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4855
Mailing Address - Country:US
Mailing Address - Phone:352-795-8832
Mailing Address - Fax:352-795-0490
Practice Address - Street 1:700 SE DR. MARTIN LUTHER KING JR. AVENUE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4855
Practice Address - Country:US
Practice Address - Phone:352-795-8832
Practice Address - Fax:352-795-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1115096313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022894000Medicaid