Provider Demographics
NPI:1679901466
Name:PARK TRAIL PLACELLC
Entity Type:Organization
Organization Name:PARK TRAIL PLACELLC
Other - Org Name:DREAM LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERISE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-814-2273
Mailing Address - Street 1:302 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4150
Mailing Address - Country:US
Mailing Address - Phone:407-814-2273
Mailing Address - Fax:404-464-7006
Practice Address - Street 1:302 N PARK AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4150
Practice Address - Country:US
Practice Address - Phone:407-814-2273
Practice Address - Fax:404-464-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12040310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004341200Medicaid