Provider Demographics
NPI:1477175636
Name:LUBIS ENTERPRISE LLC
Entity Type:Organization
Organization Name:LUBIS ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-787-3034
Mailing Address - Street 1:36321 GRAYS AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36321 GRAYS AIRPORT RD
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-5418
Practice Address - Country:US
Practice Address - Phone:352-460-0754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105612100Medicaid