Basic Information
| Provider Information | |||||||||
| NPI: | 1003159294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 433 ORANGE DRIVE, LLC | ||||||||
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| OtherOrganizationName: | GRAND VILLA OF ALTAMONTE SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13770 58TH ST N STE 312 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
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| Practice Location | |||||||||
| Address1: | 433 ORANGE DR | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327015377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072602433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 04/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | FORTE | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7277263980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | AL7103 | FL | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | AL7103 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 002973900 | 05 | FL | MEDICAID |