Healthcare Provider Details

I. General information

NPI: 1952720294
Provider Name (Legal Business Name): ALLIANCE FOUNDATION OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 N WILLIAMSON BLVD
DAYTONA BEACH FL
32114-7185
US

IV. Provider business mailing address

595 N WILLIAMSON BLVD
DAYTONA BEACH FL
32114-7185
US

V. Phone/Fax

Practice location:
  • Phone: 386-257-4400
  • Fax: 386-257-4372
Mailing address:
  • Phone: 386-257-4400
  • Fax: 386-257-4372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL5400
License Number StateFL

VIII. Authorized Official

Name: MR. RANDOLPH LEE KERNON II
Title or Position: EXECUTIVE DIRECTOR
Credential: NHA
Phone: 386-547-4686