=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831620368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK RING CAPITAL INVESTMENTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2017
-----------------------------------------------------
Last Update Date | 03/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 E WELCH RD
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32712-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-880-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3895 BISCAYNE DR
-----------------------------------------------------
City | WINTER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32708-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-951-0268
-----------------------------------------------------
Fax | 407-264-8660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | MS. SUSAN I. KORNEGAY
-----------------------------------------------------
Credential | R.N., J.D., M.B.A.
-----------------------------------------------------
Telephone | 407-951-0268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 12479
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------