Provider Demographics
NPI:1568089050
Name:FLORIDA HOMESTYLE MANOR, LLC
Entity Type:Organization
Organization Name:FLORIDA HOMESTYLE MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-541-9580
Mailing Address - Street 1:1105 SADIE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-0069
Mailing Address - Country:US
Mailing Address - Phone:205-541-9580
Mailing Address - Fax:
Practice Address - Street 1:481 DAGAMA DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34715-8037
Practice Address - Country:US
Practice Address - Phone:205-541-9580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109504600Medicaid
FL13002507OtherAGENCY FOR PERSONS WITH DISABILITIES - APD