=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508298860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDENLEA ASSISTED LIVING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2013
-----------------------------------------------------
Last Update Date | 08/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1180 JACKSON RANCH RD
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-740-9117
-----------------------------------------------------
Fax | 386-490-4889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1180 JACKSON RANCH RD
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-7900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-740-9117
-----------------------------------------------------
Fax | 386-490-4889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ ADMINISTRATOR
-----------------------------------------------------
Name | VIVIENNE POWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-740-9117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11216
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------