Provider Demographics
NPI:1871692475
Name:SHANDS AT LAKE SHORE INC
Entity type:Organization
Organization Name:SHANDS AT LAKE SHORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT & COO
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-265-0440
Mailing Address - Street 1:720 SW 2ND AVE
Mailing Address - Street 2:SUITE 360C
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-6271
Mailing Address - Country:US
Mailing Address - Phone:352-733-0060
Mailing Address - Fax:352-733-0069
Practice Address - Street 1:755 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0453
Practice Address - Country:US
Practice Address - Phone:386-755-7788
Practice Address - Fax:352-733-0069
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHANDS AT LAKE SHORE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK8077OtherMEDICARE RR
FL264258101Medicaid
FL0102AMedicare PIN