Provider Demographics
NPI:1447756655
Name:GLENVILLE PINES II ASSISTED LIVING FACILITY LLC
Entity Type:Organization
Organization Name:GLENVILLE PINES II ASSISTED LIVING FACILITY LLC
Other - Org Name:GLENVILLE PINES II ASSISTED LIVING FACILITY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:REYES-KERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-258-4056
Mailing Address - Street 1:1351 STEELE RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-5332
Mailing Address - Country:US
Mailing Address - Phone:321-258-4056
Mailing Address - Fax:
Practice Address - Street 1:211 SILVER OAK RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-5582
Practice Address - Country:US
Practice Address - Phone:321-802-4121
Practice Address - Fax:321-984-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12461310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022322700Medicaid