Provider Demographics
NPI:1093175812
Name:SENIOR GARDEN ASSSISTED LIVING, LLC
Entity Type:Organization
Organization Name:SENIOR GARDEN ASSSISTED LIVING, LLC
Other - Org Name:ASSISTED LIVING FACILITY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANIDIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-731-3392
Mailing Address - Street 1:4034 EAGLE FEATHER DR
Mailing Address - Street 2:
Mailing Address - City:OR
Mailing Address - State:FL
Mailing Address - Zip Code:32829
Mailing Address - Country:US
Mailing Address - Phone:407-731-3392
Mailing Address - Fax:
Practice Address - Street 1:4034 EAGLE FEATHER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829
Practice Address - Country:US
Practice Address - Phone:407-731-3392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12796310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility