Provider Demographics
NPI:1326399833
Name:ACADEMY ASSISTED LIVING FACILITY INC
Entity Type:Organization
Organization Name:ACADEMY ASSISTED LIVING FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINASTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAJWANTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-460-1211
Mailing Address - Street 1:1225 SOLTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-6571
Mailing Address - Country:US
Mailing Address - Phone:772-460-1211
Mailing Address - Fax:772-460-7679
Practice Address - Street 1:1225 SOLTMAN AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-6571
Practice Address - Country:US
Practice Address - Phone:772-460-1211
Practice Address - Fax:772-460-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 7824310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687422300Medicaid