Provider Demographics
NPI:1013648468
Name:CROWN ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:CROWN ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JURIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-333-2434
Mailing Address - Street 1:301 MILFORD PL
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6826
Mailing Address - Country:US
Mailing Address - Phone:386-409-7993
Mailing Address - Fax:386-409-7993
Practice Address - Street 1:301 MILFORD PL
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6826
Practice Address - Country:US
Practice Address - Phone:386-409-7993
Practice Address - Fax:386-409-7993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10584OtherAL