=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326044322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUTHERAN HAVEN NURSING HOME AND ASSISTED LIVING FACILITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 06/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 HAVEN DRIVE ATTN: NURSING HOME ADMINISTRATOR
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-365-3456
-----------------------------------------------------
Fax | 407-706-1256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2041 WEST STATE RD 426
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-365-5676
-----------------------------------------------------
Fax | 407-366-0128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. LINDA ANN KIRK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-365-5676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1300096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------