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General NPI Number Information
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NPI Number | 1720498215
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Entity Type | Organization
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Legal Business Name | FLORIDA ASSISTANT LIVING ORGANIZATION, LLC
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Dates
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Enumeration Date | 05/06/2014
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Last Update Date | 05/06/2014
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Provider Practice Location Address
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Address Line | 585 SE LAKESHORE DR
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City | MADISON
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State | FL
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Zip | 32340-2734
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Country | US
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Telephone | 850-973-2415
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Fax |
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Provider Business Mailing Address
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Address Line | 219 SE ABERNATHY WAY
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City | MADISON
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State | FL
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Zip | 32340-7044
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Country | US
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Telephone | 850-973-2415
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | WILLIE M. PEACOCK
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Credential |
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Telephone | 850-973-2380
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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 | 11916
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License Number State | FL
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