Healthcare Provider Details

I. General information

NPI: 1063321404
Provider Name (Legal Business Name): GREEN ACRES ASSISTED LIVING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 FRITZKE RD
DOVER FL
33527-3433
US

IV. Provider business mailing address

2644 FRITZKE RD
DOVER FL
33527-3433
US

V. Phone/Fax

Practice location:
  • Phone: 813-986-6157
  • Fax:
Mailing address:
  • Phone: 813-986-6157
  • 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: RAFAEL D. AVECILLAS
Title or Position: OWNER
Credential:
Phone: 813-325-9450