Provider Demographics
NPI:1629731591
Name:SPACE COAST ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:SPACE COAST ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:AUGUSTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-503-3719
Mailing Address - Street 1:1832 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5346
Mailing Address - Country:US
Mailing Address - Phone:321-567-4191
Mailing Address - Fax:888-335-7714
Practice Address - Street 1:1832 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5346
Practice Address - Country:US
Practice Address - Phone:321-567-4191
Practice Address - Fax:888-335-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10800OtherAHCA