1750981841 NPI number — SENIOR LIVING PROPERTIES III, LLC

Table of content: MRS. ANNE HANEY GOODEN MA, MSW (NPI 1194839829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750981841 NPI number — SENIOR LIVING PROPERTIES III, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR LIVING PROPERTIES III, 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:
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:
1750981841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4611 JOHNSON RD UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COCONUT CREEK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33073-4361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-691-1030
Provider Business Mailing Address Fax Number:
954-691-1036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3791 OLD CANOE CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34769-6630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-892-8502
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
954-691-1030

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: 008616500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116117600 . 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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