Basic Information
| Provider Information | |||||||||
| NPI: | 1962760108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALMORAL ASSISTED LIVING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 93 BALMORAL DR | ||||||||
| Address2: | |||||||||
| City: | LAKE PLACID | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338527000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634656584 | ||||||||
| FaxNumber: | 8634656585 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 BALMORAL DR | ||||||||
| Address2: | |||||||||
| City: | LAKE PLACID | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338527000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634656584 | ||||||||
| FaxNumber: | 8634656585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | EGAN | ||||||||
| AuthorizedOfficialFirstName: | DOREEN | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8634656584 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL11307 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 003688600 | 05 | FL | MEDICAID |