Healthcare Provider Details

I. General information

NPI: 1174195135
Provider Name (Legal Business Name): LAVIE ADULT DAY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 07/10/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2529 PREST CT
TALLAHASSEE FL
32301-0800
US

IV. Provider business mailing address

1969 S ALAFAYA TRL # 140
ORLANDO FL
32828-8732
US

V. Phone/Fax

Practice location:
  • Phone: 850-274-5150
  • Fax:
Mailing address:
  • Phone: 850-274-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RAVEN SYMONE JACKSON
Title or Position: CEO
Credential:
Phone: 850-274-5150