Provider Demographics
NPI:1548428816
Name:ALLEGIANCE PROPERTIES 1 INC
Entity Type:Organization
Organization Name:ALLEGIANCE PROPERTIES 1 INC
Other - Org Name:EASTBROOKE GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:KLINOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-699-5002
Mailing Address - Street 1:201 N SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-2947
Mailing Address - Country:US
Mailing Address - Phone:407-699-5002
Mailing Address - Fax:
Practice Address - Street 1:201 N SUNSET DR
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-2947
Practice Address - Country:US
Practice Address - Phone:407-699-5002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5355310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686580100Medicaid