Provider Demographics
NPI:1326485715
Name:LIVING SOUTHERN STYLE OF BREVARD
Entity Type:Organization
Organization Name:LIVING SOUTHERN STYLE OF BREVARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-208-7681
Mailing Address - Street 1:821 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2022
Mailing Address - Country:US
Mailing Address - Phone:321-208-7681
Mailing Address - Fax:321-208-7681
Practice Address - Street 1:821 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2022
Practice Address - Country:US
Practice Address - Phone:321-208-7681
Practice Address - Fax:321-208-7681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-27
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12363310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility