Basic Information
| Provider Information | |||||||||
| NPI: | 1629258678 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE SENIOR CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE HERITAGE AT LAKE FOREST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5433 SR 46 | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327719236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073222207 | ||||||||
| FaxNumber: | 4073023411 | ||||||||
| Practice Location | |||||||||
| Address1: | 5433 SR 46 | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327719236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073222207 | ||||||||
| FaxNumber: | 4073023411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2007 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALDWIN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4073222207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 10233 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.