=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932626751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALI ANGEL'S NESI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 08/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 864 WYOLEN ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-389-3192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 864 WYOLEN ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-389-3192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ALI ELAINE GREENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-389-3192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11369
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------