Provider Demographics
NPI:1568014991
Name:141 BEACON OPERATOR LLC
Entity Type:Organization
Organization Name:141 BEACON OPERATOR LLC
Other - Org Name:OUR HOME AT BEACON HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-320-4210
Mailing Address - Street 1:141 KAELYN LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-6180
Mailing Address - Country:US
Mailing Address - Phone:850-647-4000
Mailing Address - Fax:
Practice Address - Street 1:141 KAELYN LN
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-6180
Practice Address - Country:US
Practice Address - Phone:850-647-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-16
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104726900Medicaid