=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013214725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIE'S PLACE ASSISTED LIVING FAC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 03/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 471 ALMANSA ST NE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-3183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-727-0905
-----------------------------------------------------
Fax | 321-727-0905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 471 ALMANSA ST NE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-3183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-727-0905
-----------------------------------------------------
Fax | 321-727-0905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MARIE LOURDES PHILIPPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-549-5231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 11757
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------