Provider Demographics
NPI:1083803647
Name:PLEASANT LIVING FACILITY INC
Entity Type:Organization
Organization Name:PLEASANT LIVING FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-353-0501
Mailing Address - Street 1:1543 HILL STREET
Mailing Address - Street 2:
Mailing Address - City:JAX
Mailing Address - State:FL
Mailing Address - Zip Code:32202-1405
Mailing Address - Country:US
Mailing Address - Phone:904-353-0501
Mailing Address - Fax:904-353-8621
Practice Address - Street 1:1543 HILL STREET
Practice Address - Street 2:
Practice Address - City:JAX
Practice Address - State:FL
Practice Address - Zip Code:32202-1405
Practice Address - Country:US
Practice Address - Phone:904-353-0501
Practice Address - Fax:904-353-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9304310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility