Provider Demographics
NPI:1659019685
Name:HAINES CITY SLC OPCO LLC
Entity Type:Organization
Organization Name:HAINES CITY SLC OPCO LLC
Other - Org Name:THE CLUB AT HAINES CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PILAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-428-2480
Mailing Address - Street 1:941 W MORSE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3781
Mailing Address - Country:US
Mailing Address - Phone:305-428-2480
Mailing Address - Fax:305-428-2480
Practice Address - Street 1:301 PENINSULAR DR
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5046
Practice Address - Country:US
Practice Address - Phone:863-422-5204
Practice Address - Fax:863-422-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility