Healthcare Provider Details

I. General information

NPI: 1669759015
Provider Name (Legal Business Name): AT HOME CARE ASSISTED LIVING FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42042 CHINABERRY ST
EUSTIS FL
32736-8358
US

IV. Provider business mailing address

42042 CHINABERRY ST
EUSTIS FL
32736-8358
US

V. Phone/Fax

Practice location:
  • Phone: 407-948-0723
  • Fax: 321-256-5193
Mailing address:
  • Phone: 407-948-0723
  • Fax: 321-256-5193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KEISHA LATOYA GIST
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-948-0723