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General NPI Number Information
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NPI Number | 1578993127
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Entity Type | Organization
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Legal Business Name | TIMBERLANE LODGE ASSISTED LIVING FACILITY INC.
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Dates
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Enumeration Date | 11/19/2013
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Last Update Date | 11/19/2013
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Provider Practice Location Address
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Address Line | 415 S TIMBERLANE DR
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City | NEW SMYRNA BEACH
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State | FL
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Zip | 32168-8261
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Country | US
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Telephone | 386-428-7442
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Fax |
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Provider Business Mailing Address
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Address Line | 415 S TIMBERLANE DR
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City | NEW SMYRNA BEACH
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State | FL
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Zip | 32168-8261
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TAMELA OWENS
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Credential |
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Telephone | 386-428-7442
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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 | AL11914
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License Number State | FL
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