Basic Information
| Provider Information | |||||||||
| NPI: | 1033416466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENIOR GRACES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEART OF FLORIDA ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 BON AIR ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881196 | ||||||||
| FaxNumber: | 8636877707 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S 10TH ST | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338445601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634219581 | ||||||||
| FaxNumber: | 8634229581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2011 | ||||||||
| LastUpdateDate: | 02/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | GASMENA | ||||||||
| AuthorizedOfficialFirstName: | PIER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8635957353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL#9965 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.