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General NPI Number Information
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NPI Number | 1922617505
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Entity Type | Organization
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Legal Business Name | PALM COAST ALF MANAGEMENT LLC
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Dates
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Enumeration Date | 07/29/2020
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Last Update Date | 05/20/2021
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Provider Practice Location Address
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Address Line | 3830 OLD KINGS ROAD
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City | PALM COAST
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State | FL
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Zip | 32137
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Country | US
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Telephone | 386-307-5445
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Fax |
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Provider Business Mailing Address
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Address Line | 269 KIPLING CT
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City | LAKE MARY
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State | FL
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Zip | 32746-4124
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Country | US
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Telephone | 407-202-0046
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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. DERICK WAYNE DEETER
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Credential |
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Telephone | 407-202-0046
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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 |
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License Number State |
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