Provider Demographics
NPI:1326579178
Name:FIDELITY LIVING LLC GROUP HOME
Entity Type:Organization
Organization Name:FIDELITY LIVING LLC GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR.
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LHERISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-801-7170
Mailing Address - Street 1:1941 KINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-8619
Mailing Address - Country:US
Mailing Address - Phone:386-801-7170
Mailing Address - Fax:
Practice Address - Street 1:1941 KINGWAY DR
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-8619
Practice Address - Country:US
Practice Address - Phone:386-801-7170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility