=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841721230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASALLE ASSISTED LIVING ROCKLEDGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2017
-----------------------------------------------------
Last Update Date | 03/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3545 MURRELL RD
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-4706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-501-4756
-----------------------------------------------------
Fax | 321-417-5571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 MURRELL RD
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-501-4756
-----------------------------------------------------
Fax | 321-417-5571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MS. SALLY HAYES WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-501-4756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12979
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------