1669759015 NPI number — AT HOME CARE ASSISTED LIVING FACILITY, INC.

Table of content: (NPI 1669759015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669759015 NPI number — AT HOME CARE ASSISTED LIVING FACILITY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AT HOME CARE ASSISTED LIVING FACILITY, 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:
Provider Other Organization Name Type Code:
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:
1669759015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42042 CHINABERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUSTIS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32736-8358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-948-0723
Provider Business Mailing Address Fax Number:
321-256-5193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42042 CHINABERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32736-8358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-948-0723
Provider Business Practice Location Address Fax Number:
321-256-5193
Provider Enumeration Date:
11/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GIST
Authorized Official First Name:
KEISHA
Authorized Official Middle Name:
LATOYA
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
407-948-0723

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 311500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004347500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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