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General NPI Number Information
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NPI Number | 1558769943
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Entity Type | Organization
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Legal Business Name | ST. MARY'S HOME ASSISTED LIVING FACILITY
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Dates
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Enumeration Date | 12/17/2014
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Last Update Date | 12/18/2014
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Provider Practice Location Address
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Address Line | 718 W WINTER PARK ST
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City | ORLANDO
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State | FL
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Zip | 32804-4902
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Country | US
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Telephone | 407-843-0951
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Fax |
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Provider Business Mailing Address
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Address Line | 718 W WINTER PARK ST
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City | ORLANDO
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State | FL
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Zip | 32804-4902
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Country | US
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Telephone | 407-843-0951
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. JAMES LAYUGAN BATTUNG
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Credential |
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Telephone | 407-843-0951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | AL4860
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License Number State | FL
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