Provider Demographics
NPI:1326433681
Name:PORTLAND ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:PORTLAND ASSISTED LIVING FACILITY
Other - Org Name:PORTLAND ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOODIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:561-870-8546
Mailing Address - Street 1:8758 COBBLESTONE POINT CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4458
Mailing Address - Country:US
Mailing Address - Phone:561-870-8546
Mailing Address - Fax:
Practice Address - Street 1:4664 NW 58TH TER
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-2115
Practice Address - Country:US
Practice Address - Phone:954-603-6954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12536310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility