Provider Demographics
NPI:1104160027
Name:STILL WATERS OF LAKE CITY, INC.
Entity type:Organization
Organization Name:STILL WATERS OF LAKE CITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THREASA
Authorized Official - Middle Name:
Authorized Official - Last Name:HYSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:386-755-6560
Mailing Address - Street 1:507 NW HALL OF FAME DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4835
Mailing Address - Country:US
Mailing Address - Phone:386-755-6560
Mailing Address - Fax:386-628-5018
Practice Address - Street 1:507 NW HALL OF FAME DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4835
Practice Address - Country:US
Practice Address - Phone:386-755-6560
Practice Address - Fax:386-628-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9472311500000X, 311ZA0620X, 385H00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682130800OtherMEDICAID WAIVER