Provider Demographics
NPI:1073582219
Name:TERRACE OF DAYTONA BEACH LLC
Entity Type:Organization
Organization Name:TERRACE OF DAYTONA BEACH LLC
Other - Org Name:TERRACE OF DAYTONA BEACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-244-1054
Mailing Address - Street 1:1704 HUNTINGTON VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1484
Mailing Address - Country:US
Mailing Address - Phone:386-255-6571
Mailing Address - Fax:386-255-1949
Practice Address - Street 1:1704 HUNTINGTON VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1484
Practice Address - Country:US
Practice Address - Phone:386-255-6571
Practice Address - Fax:386-255-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1244096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021378400Medicaid
FL105822Medicare ID - Type UnspecifiedPROVIDER NUMBER