Provider Demographics
NPI:1518319631
Name:ELDERLY PRIDE ASSISTED LIVING
Entity Type:Organization
Organization Name:ELDERLY PRIDE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:KADIRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-822-6822
Mailing Address - Street 1:322 REGAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3638
Mailing Address - Country:US
Mailing Address - Phone:520-822-6822
Mailing Address - Fax:813-381-4876
Practice Address - Street 1:322 REGAL PARK DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-3638
Practice Address - Country:US
Practice Address - Phone:520-822-6822
Practice Address - Fax:813-381-4876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL128693104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness