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General NPI Number Information
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NPI Number | 1538604764
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Entity Type | Organization
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Legal Business Name | GOOD SAM'S ASSISTED LIVING RESIDENCE, LLC
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Dates
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Enumeration Date | 12/26/2016
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Last Update Date | 12/26/2016
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Provider Practice Location Address
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Address Line | 1 PEBBLE WOOD LN
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City | PALM COAST
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State | FL
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Zip | 32164-7491
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Country | US
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Telephone | 386-447-8145
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Fax |
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Provider Business Mailing Address
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Address Line | 1 PEBBLE WOOD LN
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City | PALM COAST
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State | FL
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Zip | 32164-7491
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Country | US
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Telephone | 386-447-8145
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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. L. JUDITH FERMIN-OSTRIN
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Credential | MS, RD
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Telephone | 516-524-6624
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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 | 10049
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License Number State | FL
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