=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194174912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEABODY ALF INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 PEABODY DR E
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32221-1291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-695-2967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 PEABODY DR E
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32221-1291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-695-2967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | ANTONIO MAULION DOCTOR SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-695-2967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12841
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------