Healthcare Provider Details

I. General information

NPI: 1972775203
Provider Name (Legal Business Name): WESLEY HOUSE ALF #3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28502 TALL GRASS DR
WESLEY CHAPEL FL
33543-5829
US

IV. Provider business mailing address

28502 TALL GRASS DR
WESLEY CHAPEL FL
33543-5829
US

V. Phone/Fax

Practice location:
  • Phone: 813-991-5071
  • Fax:
Mailing address:
  • Phone: 813-991-4133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11126
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL11126
License Number StateFL

VIII. Authorized Official

Name: MRS. LOLA JEYEDE
Title or Position: OWNER ADMINISTRATOR
Credential:
Phone: 813-469-4496