Basic Information
| Provider Information | |||||||||
| NPI: | 1770742231 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERLASTING GRACE ASSISTED LIVING INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARE FIRST | ||||||||
| 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: | 1325 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337011117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278236812 | ||||||||
| FaxNumber: | 7278222334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | GASMENA | ||||||||
| AuthorizedOfficialFirstName: | PIER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8635957353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | AL # 5195 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 142552800 | 05 | FL | MEDICAID |