Provider Demographics
NPI:1225499817
Name:TUCAWILLA VILLA, LLC
Entity Type:Organization
Organization Name:TUCAWILLA VILLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRY
Authorized Official - Suffix:
Authorized Official - Credentials:RN/RD
Authorized Official - Phone:407-637-0273
Mailing Address - Street 1:995 TUSCAWILLA ROAD
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708
Mailing Address - Country:US
Mailing Address - Phone:407-637-0273
Mailing Address - Fax:
Practice Address - Street 1:995 TUSCAWILLA ROAD
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708
Practice Address - Country:US
Practice Address - Phone:407-637-0273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906719311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL213000110783OtherBUSINESS TAX RECEIPT- FLORIDA DIVISION OF CORPORATION
FL6906719OtherAHCA LICENSE FOR ADULT FAMILY CARE HOME-