Basic Information
| Provider Information | |||||||||
| NPI: | 1396192134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 741 SOUTH BENEVA ROAD OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENEVA LAKES ASSISTED LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 743 S BENEVA RD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342322411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413160151 | ||||||||
| FaxNumber: | 9413160218 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 S BENEVA RD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342322411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413160151 | ||||||||
| FaxNumber: | 9413160218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | USSERY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL6563 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 017573700 | 05 | FL | MEDICAID |