Healthcare Provider Details

I. General information

NPI: 1740583293
Provider Name (Legal Business Name): LLIINGLESIDE RETIREMENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 INGLESIDE AVE
JACKSONVILLE FL
32205-7712
US

IV. Provider business mailing address

1433 INGLESIDE AVE
JACKSONVILLE FL
32205-7712
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-6677
  • Fax: 904-389-7011
Mailing address:
  • Phone: 904-389-6677
  • Fax: 904-389-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL5576
License Number StateFL

VIII. Authorized Official

Name: MR. WAJAD ALLI
Title or Position: PRESIDENT
Credential:
Phone: 904-389-6677