Provider Demographics
NPI:1285970632
Name:ADAMS, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 OLD WELAKA RD
Mailing Address - Street 2:
Mailing Address - City:WELAKA
Mailing Address - State:FL
Mailing Address - Zip Code:32193-2172
Mailing Address - Country:US
Mailing Address - Phone:386-467-2004
Mailing Address - Fax:386-467-9998
Practice Address - Street 1:611 OLD WELAKA RD
Practice Address - Street 2:
Practice Address - City:WELAKA
Practice Address - State:FL
Practice Address - Zip Code:32193-2172
Practice Address - Country:US
Practice Address - Phone:386-467-2004
Practice Address - Fax:386-467-9998
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5705310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686143100Medicaid
FL140334600Medicaid