Provider Demographics
NPI:1275968794
Name:CYPRESS MANOR ASSISTED LIVING FACILITY 11
Entity Type:Organization
Organization Name:CYPRESS MANOR ASSISTED LIVING FACILITY 11
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LURLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-825-8977
Mailing Address - Street 1:1910 NW 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-6816
Mailing Address - Country:US
Mailing Address - Phone:954-825-8977
Mailing Address - Fax:954-978-4594
Practice Address - Street 1:1910 NW 77TH AVE
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-6816
Practice Address - Country:US
Practice Address - Phone:954-825-8977
Practice Address - Fax:954-978-4594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10351310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009094200Medicaid