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General NPI Number Information
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NPI Number | 1447756655
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Entity Type | Organization
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Legal Business Name | GLENVILLE PINES II ASSISTED LIVING FACILITY LLC
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Dates
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Enumeration Date | 04/05/2018
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Last Update Date | 04/05/2018
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Provider Practice Location Address
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Address Line | 211 SILVER OAK RD NE
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City | PALM BAY
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State | FL
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Zip | 32907-5582
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Country | US
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Telephone | 321-802-4121
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Fax | 321-984-7568
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Provider Business Mailing Address
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Address Line | 1351 STEELE RD SE
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City | PALM BAY
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State | FL
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Zip | 32909-5332
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Country | US
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Telephone | 321-258-4056
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. ELIDA M REYES-KERR
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Credential |
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Telephone | 321-258-4056
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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 | AL12461
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License Number State | FL
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