Provider Demographics
NPI:1023550498
Name:DELTONA ALF MANAGEMENT
Entity Type:Organization
Organization Name:DELTONA ALF MANAGEMENT
Other - Org Name:GOLD CHOICE DELTONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DEETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-202-0046
Mailing Address - Street 1:2306 N. NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725
Mailing Address - Country:US
Mailing Address - Phone:386-259-3860
Mailing Address - Fax:386-259-3872
Practice Address - Street 1:2306 N NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725
Practice Address - Country:US
Practice Address - Phone:386-259-3860
Practice Address - Fax:386-259-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
FLAL13087310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022682200Medicaid