NPIMap

Organization Active NPI

Lakebridge a Waters Community LLC

  • Skilled Nursing Facility
  • Johnson City, TN
National Provider Identifier
1043763592
Registry record updated Aug 2, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
LAKEBRIDGE A WATERS COMMUNITY LLC
Practice address
115 Woodlawn Dr
Johnson City, TN 37604-5978
Phone
(423) 975-0095
Fax
(423) 928-0358
NPI assigned
Aug 2, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 2, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Moishe Gubin
Title
Member
Phone
(708) 449-1900

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

115 Woodlawn Dr
Johnson City, TN 37604-5978

Mailing address

115 Woodlawn Dr
Johnson City, TN 37604-5978
Phone (423) 975-0095

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170104002426 TN Part A Provider - Skilled Nursing Facility 9133400161 Practice locations: Johnson City, TN

Skilled nursing facility certification: CCN 445358

Legal name
LAKEBRIDGE, A WATERS COMMUNITY, LLC
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Sep 26, 1995
Last certification
Jul 25, 2023
Beds
109
Ownership / control type
Individual
Most recent change of ownership
Aug 1, 2016
Organization structure
LLCProprietary
Enrollment address
115 Woodlawn Dr
Johnson City, TN 37604-5978
Nursing home name
LAKEBRIDGE, A WATERS COMMUNITY, LLC
Affiliated entity
INFINITY HEALTHCARE CONSULTING

Care Compare: Nursing home

Medicare Care Compare
Listed as
Lakebridge, a Waters Community, LLCCCN 445358
Overall star rating
3 of 5
Health inspections
4 of 5
Staffing
1 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Individual
Certified
Sep 26, 1995
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
109104.7 residents per day on average
Chain
Infinity Healthcare Consulting69 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gubin Enterprises Limited Partnership Organization, South Bend, IN 5% Or Greater Direct Ownership Interest Aug 1, 2016 50%
Michael Blisko Individual 5% Or Greater Direct Ownership Interest Aug 1, 2016 50%
Wesley Garland Individual W-2 Managing EmployeeAdministrator Oct 5, 2019

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1470096000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1470096000000",
    "number": "1043763592",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 WOODLAWN DR",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376045978",
            "telephone_number": "423-975-0095",
            "fax_number": "423-928-0358"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 WOODLAWN DR",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376045978",
            "telephone_number": "423-975-0095",
            "fax_number": "423-928-0358"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKEBRIDGE A WATERS COMMUNITY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-08-02",
        "last_updated": "2016-08-02",
        "status": "A",
        "authorized_official_last_name": "GUBIN",
        "authorized_official_first_name": "MOISHE",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "708-449-1900"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Johnson City, TN

Sources for this page

Verify at the official NPI Registry.