Provider Demographics
NPI:1689916546
Name:FLORIDA SOUTHERN ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:FLORIDA SOUTHERN ASSISTED LIVING LLC
Other - Org Name:INGLESIDE RETIREMENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-571-5366
Mailing Address - Street 1:1019 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5746
Mailing Address - Country:US
Mailing Address - Phone:843-571-5366
Mailing Address - Fax:843-571-5659
Practice Address - Street 1:1433 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7712
Practice Address - Country:US
Practice Address - Phone:843-571-5399
Practice Address - Fax:843-571-5659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility