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General NPI Number Information
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NPI Number | 1770775413
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Entity Type | Organization
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Legal Business Name | A BANYAN RESIDENCE ASSISTED LIVING LLC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 12/17/2009
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Provider Practice Location Address
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Address Line | 100 BASE AVE E
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City | VENICE
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State | FL
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Zip | 34285-3809
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Country | US
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Telephone | 941-412-4748
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Fax |
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Provider Business Mailing Address
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Address Line | 3107 NE 40TH CT
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-6413
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Country | US
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Telephone | 954-454-2345
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Fax | 954-457-8242
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. GREG A ANDERSON
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Credential |
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Telephone | 954-454-2345
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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 | APPLIED FOR IT
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License Number State | FL
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