Provider Demographics
NPI:1699036285
Name:SHADY OAKS REST HOME INC.
Entity Type:Organization
Organization Name:SHADY OAKS REST HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-562-0870
Mailing Address - Street 1:1208 KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117
Mailing Address - Country:US
Mailing Address - Phone:386-253-6993
Mailing Address - Fax:
Practice Address - Street 1:1208 KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-253-6993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10293310400000X
FL10293310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility