Provider Demographics
NPI:1457318461
Name:ALLIANCE FOUNDATION OF FLORIDA INC
Entity Type:Organization
Organization Name:ALLIANCE FOUNDATION OF FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:KERNON
Authorized Official - Suffix:II
Authorized Official - Credentials:LNHA
Authorized Official - Phone:386-257-4400
Mailing Address - Street 1:595 N WILLIAMSON BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-7185
Mailing Address - Country:US
Mailing Address - Phone:386-257-4400
Mailing Address - Fax:386-257-4372
Practice Address - Street 1:595 N WILLIAMSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-7185
Practice Address - Country:US
Practice Address - Phone:386-257-4400
Practice Address - Fax:386-257-4372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCEFOUNDATION OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-26
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5400310400000X
FLSNF1248096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685701900Medicaid
FL025875000Medicaid
FL105570Medicare ID - Type Unspecified