Provider Demographics
NPI:1619329422
Name:ASSISTED LOVELY LIVING FACILITY LLC
Entity Type:Organization
Organization Name:ASSISTED LOVELY LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:RENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-984-8882
Mailing Address - Street 1:2214 MISTY WAY LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-1455
Mailing Address - Country:US
Mailing Address - Phone:321-984-8882
Mailing Address - Fax:
Practice Address - Street 1:1702 TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-9034
Practice Address - Country:US
Practice Address - Phone:321-984-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12837310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL12837OtherACHA