=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013250570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. PHILLIPS RESIDENTIAL LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2013
-----------------------------------------------------
Last Update Date | 04/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6311 VINELAND RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-226-3686
-----------------------------------------------------
Fax | 407-226-3686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6311 VINELAND ROAD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-226-3686
-----------------------------------------------------
Fax | 407-226-3686
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CORAZON CELESTINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-451-9929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11921
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------