Provider Demographics
NPI:1407437106
Name:AGNES COTTAGE LLC
Entity Type:Organization
Organization Name:AGNES COTTAGE LLC
Other - Org Name:COQUINA COVE ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-550-2211
Mailing Address - Street 1:10957 LEDGEMENT LN
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6423
Mailing Address - Country:US
Mailing Address - Phone:240-550-2211
Mailing Address - Fax:407-902-0121
Practice Address - Street 1:3739 SUNRISE OAKS DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-8651
Practice Address - Country:US
Practice Address - Phone:386-265-4732
Practice Address - Fax:407-902-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility