Provider Demographics
NPI:1205194545
Name:THE WILSON PLACE
Entity Type:Organization
Organization Name:THE WILSON PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:LYLE
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:321-613-2867
Mailing Address - Street 1:117 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3981
Mailing Address - Country:US
Mailing Address - Phone:321-613-2867
Mailing Address - Fax:321-396-7855
Practice Address - Street 1:117 WILSON AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3981
Practice Address - Country:US
Practice Address - Phone:321-613-2867
Practice Address - Fax:321-396-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11786310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility