Provider Demographics
NPI:1407123458
Name:ALTERNATIVE LIVING INC.
Entity Type:Organization
Organization Name:ALTERNATIVE LIVING INC.
Other - Org Name:CRESTVIEW MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FRALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-833-9212
Mailing Address - Street 1:207 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5066
Mailing Address - Country:US
Mailing Address - Phone:850-833-9165
Mailing Address - Fax:850-833-9165
Practice Address - Street 1:603 N PEARL ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2749
Practice Address - Country:US
Practice Address - Phone:850-689-7850
Practice Address - Fax:850-689-7974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5649310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676877600Medicaid