Provider Demographics
NPI:1902452964
Name:MARKET STREET EAST LAKE SL, LLC
Entity Type:Organization
Organization Name:MARKET STREET EAST LAKE SL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-539-4560
Mailing Address - Street 1:445 24TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7502
Mailing Address - Country:US
Mailing Address - Phone:772-539-4560
Mailing Address - Fax:772-257-6934
Practice Address - Street 1:833 E LAKE RD N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34688-6308
Practice Address - Country:US
Practice Address - Phone:727-202-9314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility