Provider Demographics
NPI:1114158532
Name:PHOENIX SENIOR LIVING III, INC.
Entity Type:Organization
Organization Name:PHOENIX SENIOR LIVING III, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:JANETA
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:954-682-1985
Mailing Address - Street 1:10020 NW 50TH MNR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2419
Mailing Address - Country:US
Mailing Address - Phone:954-682-1985
Mailing Address - Fax:
Practice Address - Street 1:10020 NW 50TH MNR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2419
Practice Address - Country:US
Practice Address - Phone:954-682-1985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10637310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility