=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033897889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1031CF PALM COAST MT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2023
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3830 OLD KINGS RD
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-9262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-307-5445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2603 MAIN ST STE 1050
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92614-4282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-533-1031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | EDWARD FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 844-533-1031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------