Provider Demographics
NPI:1659799112
Name:PRESTIGE MANOR LLC
Entity Type:Organization
Organization Name:PRESTIGE MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-307-6333
Mailing Address - Street 1:6333 SE BABB RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-4280
Mailing Address - Country:US
Mailing Address - Phone:352-307-6333
Mailing Address - Fax:352-245-1748
Practice Address - Street 1:6333 SE BABB RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4280
Practice Address - Country:US
Practice Address - Phone:352-307-6333
Practice Address - Fax:352-245-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10889310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility