Provider Demographics
NPI:1619220324
Name:JEROLL CARE ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:JEROLL CARE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JHOANE
Authorized Official - Middle Name:EUNICE
Authorized Official - Last Name:LALEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:321-266-5166
Mailing Address - Street 1:107 COFFEE ST SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-8561
Mailing Address - Country:US
Mailing Address - Phone:321-266-5166
Mailing Address - Fax:321-821-1525
Practice Address - Street 1:107 COFFEE ST SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-8561
Practice Address - Country:US
Practice Address - Phone:321-266-5166
Practice Address - Fax:321-821-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12239310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003357400Medicaid