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General NPI Number Information
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NPI Number | 1356714414
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Entity Type | Organization
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Legal Business Name | ACACIA GROVE ASSISTED LIVING FACILITY LLC
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 11/10/2015
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Provider Practice Location Address
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Address Line | 2485 RIDGECREST AVE
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City | ORANGE PARK
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State | FL
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Zip | 32065-6236
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Country | US
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Telephone | 904-602-5550
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Fax |
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Provider Business Mailing Address
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Address Line | 2485 RIDGECREST AVE
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City | ORANGE PARK
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State | FL
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Zip | 32065-6236
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Country | US
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Telephone | 904-602-5550
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. DOROTHY MAE ARIAS
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Credential | RN
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Telephone | 904-602-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 12749
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License Number State | FL
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