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General NPI Number Information
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NPI Number | 1831593383
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Entity Type | Organization
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Legal Business Name | FREMONT ASSISTED LIVING
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Dates
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Enumeration Date | 10/13/2014
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | 2200 BAYVIEW RD
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City | JACKSONVILLE
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State | FL
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Zip | 32210-4213
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Country | US
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Telephone | 904-800-2653
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Fax | 904-800-2656
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Provider Business Mailing Address
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Address Line | 2200 BAYVIEW RD
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City | JACKSONVILLE
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State | FL
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Zip | 32210-4213
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Country | US
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Telephone | 904-800-2653
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Fax | 904-800-2656
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Authorized Official
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Title or Position | MANAGER
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Name | ANGELUS GALLO PANCHO
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Credential |
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Telephone | 904-800-2653
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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 | AL12549
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License Number State | FL
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