Provider Demographics
NPI:1568880565
Name:2065 INC DBA FORT LAUDERDALE RETIREMENT HOME
Entity Type:Organization
Organization Name:2065 INC DBA FORT LAUDERDALE RETIREMENT HOME
Other - Org Name:FORT LAUDERDALE RETIREMENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:954-270-6322
Mailing Address - Street 1:401 SE 12TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1919
Mailing Address - Country:US
Mailing Address - Phone:954-270-6322
Mailing Address - Fax:954-423-1674
Practice Address - Street 1:401 SE 12TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1919
Practice Address - Country:US
Practice Address - Phone:954-270-6322
Practice Address - Fax:954-423-1674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALF66343104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140290100Medicaid