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General NPI Number Information
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NPI Number | 1104247717
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Entity Type | Organization
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Legal Business Name | COUNTRY MANOR ASSISTED LIVING & RETIREMENT HOME, LLC
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Dates
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Enumeration Date | 12/27/2013
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Last Update Date | 12/27/2013
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Provider Practice Location Address
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Address Line | 1152 OLD HAMMOCK RD
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City | PORT ORANGE
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State | FL
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Zip | 32129-5016
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Country | US
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Telephone | 386-265-5935
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Fax | 386-265-5937
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Provider Business Mailing Address
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Address Line | 1152 OLD HAMMOCK RD
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City | PORT ORANGE
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State | FL
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Zip | 32129-5016
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Country | US
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Telephone | 386-265-5935
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Fax | 386-265-5937
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ARNULFO SALGADO SIMONDAC
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Credential |
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Telephone | 386-589-6252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 12025
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License Number State | FL
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