Provider Demographics
NPI:1376896555
Name:HIDDEN OAKS ALF, INC
Entity Type:Organization
Organization Name:HIDDEN OAKS ALF, INC
Other - Org Name:THE SUSAN REWIS HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS OF EDUCATION
Authorized Official - Phone:386-938-1149
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32053-0180
Mailing Address - Country:US
Mailing Address - Phone:386-938-2097
Mailing Address - Fax:386-938-2636
Practice Address - Street 1:7216 NW 22ND DR
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:FL
Practice Address - Zip Code:32053-2351
Practice Address - Country:US
Practice Address - Phone:386-938-2097
Practice Address - Fax:386-938-2636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIDDEN OAKS ALF, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-24
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693600801Medicaid
FL693600800Medicaid