Provider Demographics
NPI:1407293301
Name:VANDERBILT BEACH ASSISTED LIVING FACILITY,LLC
Entity Type:Organization
Organization Name:VANDERBILT BEACH ASSISTED LIVING FACILITY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:239-910-2283
Mailing Address - Street 1:517 100TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2235
Mailing Address - Country:US
Mailing Address - Phone:239-597-5177
Mailing Address - Fax:239-514-7253
Practice Address - Street 1:517 100TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-2235
Practice Address - Country:US
Practice Address - Phone:239-597-5177
Practice Address - Fax:239-514-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5582310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility