1487178166 NPI number — RESTORATION HOMES ASSISTED LIVING FACILITY

Table of content: (NPI 1487178166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487178166 NPI number — RESTORATION HOMES ASSISTED LIVING FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORATION HOMES ASSISTED LIVING FACILITY
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:
CAYONNA M. MOORE
Provider Other Organization Name Type Code:
5
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:
1487178166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 MANSEAU DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33880-1719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-875-4961
Provider Business Mailing Address Fax Number:
863-229-7186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 MANSEAU DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33880-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-875-4961
Provider Business Practice Location Address Fax Number:
863-229-7186
Provider Enumeration Date:
08/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE-STRODDER
Authorized Official First Name:
CAYONNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
863-662-0550

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 014960000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".