Provider Demographics
NPI:1083006639
Name:MARJORIE DOREEN THOMPSON
Entity Type:Organization
Organization Name:MARJORIE DOREEN THOMPSON
Other - Org Name:PEACE HAVEN ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:DOREEN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-727-3380
Mailing Address - Street 1:1090 DOUGLAS ST SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-3833
Mailing Address - Country:US
Mailing Address - Phone:321-727-3380
Mailing Address - Fax:
Practice Address - Street 1:1090 DOUGLAS ST SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-3833
Practice Address - Country:US
Practice Address - Phone:321-727-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11341310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000429700Medicaid