Provider Demographics
NPI:1528375698
Name:ALTA HEALTHCARE GROUP, INC
Entity Type:Organization
Organization Name:ALTA HEALTHCARE GROUP, INC
Other - Org Name:ALTA HEALTHCARE @ DEERWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-435-2402
Mailing Address - Street 1:4279 FOX HOLLOW CIR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5240
Mailing Address - Country:US
Mailing Address - Phone:407-435-2402
Mailing Address - Fax:407-695-7720
Practice Address - Street 1:122 N DEERWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3754
Practice Address - Country:US
Practice Address - Phone:407-435-2402
Practice Address - Fax:407-695-7720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10515310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL688818600Medicaid