Healthcare Provider Details

I. General information

NPI: 1982910568
Provider Name (Legal Business Name): ENON COUNTRY MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 ENON SCHOOL RD
WALNUT HILL FL
32568-1531
US

IV. Provider business mailing address

7701 ENON SCHOOL RD
WALNUT HILL FL
32568-1531
US

V. Phone/Fax

Practice location:
  • Phone: 850-327-4459
  • Fax:
Mailing address:
  • Phone: 850-327-4459
  • Fax: 850-327-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL 5153
License Number StateFL

VIII. Authorized Official

Name: MR. AL GREGORY
Title or Position: OWNER
Credential:
Phone: 850-327-4459