Provider Demographics
NPI:1417482654
Name:TROUT RIVER ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:TROUT RIVER ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-887-3931
Mailing Address - Street 1:9821 RIBAULT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-1492
Mailing Address - Country:US
Mailing Address - Phone:904-405-5867
Mailing Address - Fax:904-862-6916
Practice Address - Street 1:4106 WOODLEY CREEK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-9184
Practice Address - Country:US
Practice Address - Phone:904-887-3931
Practice Address - Fax:904-862-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12997310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility