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General NPI Number Information
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NPI Number | 1902149883
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Entity Type | Organization
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Legal Business Name | LILAC HOUSE LLC
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Dates
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Enumeration Date | 03/29/2013
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Last Update Date | 08/29/2022
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Provider Practice Location Address
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Address Line | 1770 S LILAC CIR
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City | TITUSVILLE
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State | FL
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Zip | 32796-3274
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Country | US
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Telephone | 321-626-6672
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Fax |
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Provider Business Mailing Address
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Address Line | 1770 S LILAC CIR
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City | TITUSVILLE
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State | FL
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Zip | 32796-3274
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Country | US
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Telephone | 321-626-6672
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MR. AMBER BROOKS
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Credential |
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Telephone | 321-458-8327
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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 | AL11050
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License Number State | FL
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