Provider Demographics
NPI:1588014047
Name:HOMECARE ASSISTED LIVING
Entity Type:Organization
Organization Name:HOMECARE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:BADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-375-2672
Mailing Address - Street 1:1906 BELHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7663
Mailing Address - Country:US
Mailing Address - Phone:904-375-2672
Mailing Address - Fax:904-375-2718
Practice Address - Street 1:1906 BELHAVEN DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7663
Practice Address - Country:US
Practice Address - Phone:904-375-2672
Practice Address - Fax:904-375-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12803310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility