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General NPI Number Information
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NPI Number | 1831489632
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Entity Type | Organization
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Legal Business Name | SOUTHERN LIVE IN
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Dates
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Enumeration Date | 04/13/2011
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Last Update Date | 03/22/2023
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Provider Practice Location Address
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Address Line | 619 PRINCETON ST
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City | BRANDON
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State | FL
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Zip | 33511-7129
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Country | US
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Telephone | 813-655-0822
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Fax | 813-681-1482
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Provider Business Mailing Address
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Address Line | PO BOX 3528
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City | APOLLO BEACH
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State | FL
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Zip | 33572-1005
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Country | US
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Telephone | 813-655-0822
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Fax | 813-681-1482
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Authorized Official
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Title or Position | PRESIDENT
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Name | MELONIE BESSETTE
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Credential | AMINISTRATOR
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Telephone | 813-655-0822
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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 | AL9890
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License Number State | FL
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