Provider Demographics
NPI:1407937709
Name:ANDALUSIA MANOR LLC
Entity Type:Organization
Organization Name:ANDALUSIA MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SAL-LEE
Authorized Official - Middle Name:SHA-REE
Authorized Official - Last Name:SASSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-222-4544
Mailing Address - Street 1:670 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420
Mailing Address - Country:US
Mailing Address - Phone:334-222-4544
Mailing Address - Fax:334-222-4737
Practice Address - Street 1:670 MOORE RD
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420
Practice Address - Country:US
Practice Address - Phone:334-222-4544
Practice Address - Fax:334-222-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4757890SMedicaid
AL5883290001Medicare NSC
AL015416Medicare ID - Type Unspecified