Healthcare Provider Details

I. General information

NPI: 1083145072
Provider Name (Legal Business Name): EASTON'S PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 04/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W JAMES LEE BLVD
CRESTVIEW FL
32536-5409
US

IV. Provider business mailing address

2301 W JAMES LEE BLVD
CRESTVIEW FL
32536-5409
US

V. Phone/Fax

Practice location:
  • Phone: 850-306-2618
  • Fax:
Mailing address:
  • Phone: 850-306-2618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL12975
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberAL12975
License Number StateFL

VIII. Authorized Official

Name: INDIANA HEIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 850-603-5917