1407123458 NPI number — ALTERNATIVE LIVING INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407123458 NPI number — ALTERNATIVE LIVING INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALTERNATIVE LIVING INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRESTVIEW MANOR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407123458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 HOSPITAL DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32548-5066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-833-9165
Provider Business Mailing Address Fax Number:
850-833-9165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 N PEARL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-689-7850
Provider Business Practice Location Address Fax Number:
850-689-7974
Provider Enumeration Date:
11/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FRALEY
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ASSISTANT ADMINISTRATOR
Authorized Official Telephone Number:
850-833-9212

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL5649 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 676877600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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