Basic Information
| Provider Information | |||||||||
| NPI: | 1851510598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN SENIOR LIVING OF DADE CITY FL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EDWINOLA RETIREMENT COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5692 STRAND CT | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341103389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399633400 | ||||||||
| FaxNumber: | 2399633401 | ||||||||
| Practice Location | |||||||||
| Address1: | 14235 EDWINOLA WAY | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525676500 | ||||||||
| FaxNumber: | 3525670272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | DORENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MIS | ||||||||
| AuthorizedOfficialTelephone: | 2399633400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL7295 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 140899200 | 05 | FL | MEDICAID | 686252700 | 05 | FL | MEDICAID |