Provider Demographics
NPI:1497453088
Name:SILVER SPARKS RESIDENTIAL CARE LLC DBA ADULT LEISURE LIVING
Entity Type:Organization
Organization Name:SILVER SPARKS RESIDENTIAL CARE LLC DBA ADULT LEISURE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GORDON THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-506-6778
Mailing Address - Street 1:15650 W BUNCHE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6965
Mailing Address - Country:US
Mailing Address - Phone:305-705-2347
Mailing Address - Fax:
Practice Address - Street 1:15650 W BUNCHE PARK DR
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33054-6965
Practice Address - Country:US
Practice Address - Phone:305-705-2347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12063OtherAGENCY FOR HEALTHCARE ADMINISTRATION LICENSE