Provider Demographics
NPI:1528562493
Name:PURE RESTORATION ASSISTED LIVING OF CRYSTAL RIVER, LLC
Entity Type:Organization
Organization Name:PURE RESTORATION ASSISTED LIVING OF CRYSTAL RIVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-750-6224
Mailing Address - Street 1:125 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-4425
Mailing Address - Country:US
Mailing Address - Phone:321-750-6224
Mailing Address - Fax:
Practice Address - Street 1:125 NE 9TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4425
Practice Address - Country:US
Practice Address - Phone:321-750-6224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLATN705105Medicaid