10D0990646 CLIA NUMBER - WICKSHIRE PORT ORANGE FL OPCO, LLC

Laboratory Demographics

CLIA Number: 10D0990646

Facility Name: WICKSHIRE PORT ORANGE FL OPCO, LLC

Facility Address:
1675 DUNLAWTON AVE
PORT ORANGE, FL
ZIP 32127
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Facility Phone Number: 386 761-1055

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1023616943

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

CLIA Record

Field Name	Field Value
CLIA Number	10D0990646
LAB Type	Assisted Living Facility
Facility Name	WICKSHIRE PORT ORANGE FL OPCO, LLC
Street	1675 DUNLAWTON AVE
City	PORT ORANGE
State	FL
ZIP	32127
Phone	386 761-1055
CertificateType	4
CertificateEffectiveDate	8/28/2023
CertificateExpirationDate	8/27/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024