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General NPI Number Information
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NPI Number | 1790294742
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Entity Type | Organization
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Legal Business Name | DELAND MANOR ASSISTED LIVING CORP
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Dates
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Enumeration Date | 09/21/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 245 S. AMELIA AVE
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City | DELAND
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State | FL
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Zip | 32724
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Country | US
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Telephone | 386-624-7777
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Fax | 386-279-7341
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Provider Business Mailing Address
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Address Line | 245 S AMELIA AVE
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City | DELAND
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State | FL
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Zip | 32724-5913
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Country | US
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Telephone | 386-624-7777
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Fax | 386-279-7341
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. DENNIS FABIAN JAVIER
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Credential |
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Telephone | 407-453-6541
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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 | AL12944
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License Number State | FL
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