1922617505 NPI number — PALM COAST ALF MANAGEMENT LLC

Table of content: (NPI 1922617505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922617505 NPI number — PALM COAST ALF MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM COAST ALF MANAGEMENT LLC
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:
GOLD CHOICE PALM COAST
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:
1922617505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 KIPLING CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-202-0046
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3830 OLD KINGS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-307-5445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEETER
Authorized Official First Name:
DERICK
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
407-202-0046

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13591 . This is a "ASSISTED LIVING FACILITY LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 110284500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".