Provider Demographics
NPI:1508239047
Name:A HOME SWEET HOME ALF OF JAX, INC.
Entity Type:Organization
Organization Name:A HOME SWEET HOME ALF OF JAX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANISHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-772-0651
Mailing Address - Street 1:6838 MEDELLIN CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4922
Mailing Address - Country:US
Mailing Address - Phone:904-772-0651
Mailing Address - Fax:904-438-5726
Practice Address - Street 1:6838 MEDELLIN CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-4922
Practice Address - Country:US
Practice Address - Phone:904-772-0651
Practice Address - Fax:904-438-5726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility