Provider Demographics
NPI:1558769943
Name:ST. MARY'S HOME ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:ST. MARY'S HOME ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LAYUGAN
Authorized Official - Last Name:BATTUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-843-0951
Mailing Address - Street 1:718 W WINTER PARK ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4902
Mailing Address - Country:US
Mailing Address - Phone:407-843-0951
Mailing Address - Fax:
Practice Address - Street 1:718 W WINTER PARK ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4902
Practice Address - Country:US
Practice Address - Phone:407-843-0951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4860302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization