=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831434547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PLACE TO GROW LCC ALF
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2012
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 VALLEY DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-689-6346
-----------------------------------------------------
Fax | 813-689-6346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 VALLEY DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33510-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-689-6346
-----------------------------------------------------
Fax | 813-689-6346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. HEATHER TOLEDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-469-6764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL 12293
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------