Provider Demographics
NPI:1427393289
Name:FLORRY CREATIVE CARE CORPORATION
Entity Type:Organization
Organization Name:FLORRY CREATIVE CARE CORPORATION
Other - Org Name:COVENTRY ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-704-6918
Mailing Address - Street 1:415 N. WILDER RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33566
Mailing Address - Country:US
Mailing Address - Phone:813-441-4761
Mailing Address - Fax:813-704-4745
Practice Address - Street 1:415 N. WILDER RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33566
Practice Address - Country:US
Practice Address - Phone:813-441-4761
Practice Address - Fax:813-704-4745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORRY CREATIVE CARE CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-05
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12181310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104395400Medicaid