Provider Demographics
NPI:1689114423
Name:QUEEN ELAINE ASSISTED LIVING FACILITY, LLC
Entity Type:Organization
Organization Name:QUEEN ELAINE ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:407-209-3242
Mailing Address - Street 1:5840 RED BUG LAKE RD STE 495
Mailing Address - Street 2:
Mailing Address - City:WINTER SPGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5011
Mailing Address - Country:US
Mailing Address - Phone:407-209-3242
Mailing Address - Fax:
Practice Address - Street 1:5840 RED BUG LAKE RD STE 495
Practice Address - Street 2:
Practice Address - City:WINTER SPGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5011
Practice Address - Country:US
Practice Address - Phone:407-209-3242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12973310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility