Provider Demographics
NPI:1982905097
Name:WELLSPRING ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:WELLSPRING ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILFRED
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-715-1000
Mailing Address - Street 1:PO BOX 280339
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-0339
Mailing Address - Country:US
Mailing Address - Phone:813-715-1000
Mailing Address - Fax:813-425-6925
Practice Address - Street 1:37815 15TH AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-3217
Practice Address - Country:US
Practice Address - Phone:813-715-1000
Practice Address - Fax:813-425-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10854310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142709100Medicaid