Healthcare Provider Details

I. General information

NPI: 1326579178
Provider Name (Legal Business Name): FIDELITY LIVING LLC GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 KINGWAY DR
DELTONA FL
32738-8619
US

IV. Provider business mailing address

1941 KINGWAY DR
DELTONA FL
32738-8619
US

V. Phone/Fax

Practice location:
  • Phone: 386-801-7170
  • Fax:
Mailing address:
  • Phone: 386-801-7170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. NATACHA LHERISSON
Title or Position: MGR.
Credential:
Phone: 386-801-7170