Provider Demographics
NPI:1386213320
Name:202 BEVERLY LLC
Entity Type:Organization
Organization Name:202 BEVERLY LLC
Other - Org Name:REFUGE AT NEW LIFE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYNOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:678-255-5990
Mailing Address - Street 1:202 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5504
Mailing Address - Country:US
Mailing Address - Phone:813-655-8454
Mailing Address - Fax:813-315-9379
Practice Address - Street 1:202 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5504
Practice Address - Country:US
Practice Address - Phone:678-255-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility