Provider Demographics
NPI:1417371857
Name:ACTIVE SENIOR LIVING RESIDENCE
Entity Type:Organization
Organization Name:ACTIVE SENIOR LIVING RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BESU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-629-4734
Mailing Address - Street 1:9057 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33351-4305
Mailing Address - Country:US
Mailing Address - Phone:954-721-1115
Mailing Address - Fax:
Practice Address - Street 1:9057 NW 57TH ST
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33351-4305
Practice Address - Country:US
Practice Address - Phone:954-721-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9969310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility