Provider Demographics
NPI:1700194222
Name:ENON COUNTRY MANOR ALF LLC
Entity Type:Organization
Organization Name:ENON COUNTRY MANOR ALF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MM
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-806-7007
Mailing Address - Street 1:PO BOX 110363
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RCH
Mailing Address - State:FL
Mailing Address - Zip Code:34211-0005
Mailing Address - Country:US
Mailing Address - Phone:941-809-6147
Mailing Address - Fax:941-567-4753
Practice Address - Street 1:7701 ENON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILL
Practice Address - State:FL
Practice Address - Zip Code:32568-1531
Practice Address - Country:US
Practice Address - Phone:941-809-6147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5153310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140281100Medicaid