Provider Demographics
NPI:1497219133
Name:YOUNG HEARTS EXTENDED ASSISTED LIVING FACILITY, LLC
Entity Type:Organization
Organization Name:YOUNG HEARTS EXTENDED ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKITA
Authorized Official - Middle Name:LATRICE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, RN-BC
Authorized Official - Phone:904-769-1122
Mailing Address - Street 1:1410 NE 219TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTEY
Mailing Address - State:FL
Mailing Address - Zip Code:32058-4387
Mailing Address - Country:US
Mailing Address - Phone:904-769-1122
Mailing Address - Fax:
Practice Address - Street 1:1410 NE 219TH ST
Practice Address - Street 2:
Practice Address - City:LAWTEY
Practice Address - State:FL
Practice Address - Zip Code:32058-4387
Practice Address - Country:US
Practice Address - Phone:904-769-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility