Wellsprings Residence LLC

Primary specialty

Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X

Legal business name

WELLSPRINGS RESIDENCE LLC

Practice address

700 E Welch Rd
Apopka, FL 32712-2921

Phone

(407) 880-8020

Fax

(407) 264-8660

NPI assigned

Jul 25, 2018

Last updated

Oct 6, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mrs. Susan I. Kornegay, JD, MBA, BSN, RN

Title

Authorized Managing Member

Phone

(407) 951-0268

Specialties & licenses 13

Addresses

Other identifiers 4

Other names 1

• Black Ring Capital Investments LLC Former legal business name

Electronic endpoints 1

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

{
    "created_epoch": "1532476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665014400000",
    "number": "1275010969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 E WELCH RD",
            "city": "APOPKA",
            "state": "FL",
            "postal_code": "327122921",
            "telephone_number": "407-880-8020",
            "fax_number": "407-264-8660"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 E WELCH RD",
            "city": "APOPKA",
            "state": "FL",
            "postal_code": "327122921",
            "telephone_number": "407-880-8020",
            "fax_number": "407-264-8660"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSPRINGS RESIDENCE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-25",
        "last_updated": "2022-10-06",
        "certification_date": "2022-10-06",
        "status": "A",
        "authorized_official_last_name": "KORNEGAY",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "I.",
        "authorized_official_title_or_position": "AUTHORIZED MANAGING MEMBER",
        "authorized_official_telephone_number": "407-951-0268",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "JD, MBA, BSN, RN"
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251J00000X",
            "taxonomy_group": "",
            "desc": "Nursing Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QA0600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Day Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "311500000X",
            "taxonomy_group": "",
            "desc": "Alzheimer Center (Dementia Center)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "385H00000X",
            "taxonomy_group": "",
            "desc": "Respite Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "253Z00000X",
            "taxonomy_group": "",
            "desc": "In Home Supportive Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100011400",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SAM UNIQUE ENTITY ID",
            "identifier": "GJHJCRUH32H5",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SAM CAGE CODE",
            "identifier": "96EQ6",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AGENCY FOR HEALTHCARE ADMINISTRATION (AHCA)",
            "identifier": "11968599",
            "state": "FL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "office@wellspringsresidence.com",
            "affiliation": "N",
            "endpointDescription": "Email Address",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "All Direct Communications",
            "address_1": "700 E Welch Rd",
            "city": "Apopka",
            "state": "FL",
            "country_code": "US",
            "postal_code": "327122921",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Black Ring Capital Investments LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Nursing Facility/Intermediate Care Facility in Apopka, FL
• Providers in Apopka, FL by specialty
• Nursing Facility/Intermediate Care Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.