=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538686746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBOR HOUSE ALF LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12080 SW HIGHWAY 484
-----------------------------------------------------
City | DUNNELLON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34432-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-489-9698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12080 SW HIGHWAY 484
-----------------------------------------------------
City | DUNNELLON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34432-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ZEVI KOHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-338-2999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 8142
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------