Provider Demographics
NPI:1235517988
Name:CRISTAL PALACE RESORT PB, LLC.
Entity Type:Organization
Organization Name:CRISTAL PALACE RESORT PB, LLC.
Other - Org Name:CRISTAL PALACE RESORT PB LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHENIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-951-2989
Mailing Address - Street 1:1881 PALM BAY RD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2978
Mailing Address - Country:US
Mailing Address - Phone:321-951-2989
Mailing Address - Fax:
Practice Address - Street 1:1881 PALM BAY RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2978
Practice Address - Country:US
Practice Address - Phone:321-951-2989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12660310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility