Provider Demographics
NPI:1669632857
Name:AVALON PARK RETIREMENT RESIDENCE
Entity Type:Organization
Organization Name:AVALON PARK RETIREMENT RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KULNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-981-4822
Mailing Address - Street 1:600 N 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7857
Mailing Address - Country:US
Mailing Address - Phone:954-981-4822
Mailing Address - Fax:954-963-9561
Practice Address - Street 1:600 N 62ND AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-7857
Practice Address - Country:US
Practice Address - Phone:954-981-4822
Practice Address - Fax:954-963-9561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6653310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693228200Medicaid