Provider Demographics
NPI:1700211794
Name:AUDREYSTLC I
Entity Type:Organization
Organization Name:AUDREYSTLC I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:BEVERLY
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-368-9993
Mailing Address - Street 1:10620 NE 29TH CT
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322
Mailing Address - Country:US
Mailing Address - Phone:754-368-9999
Mailing Address - Fax:954-306-2745
Practice Address - Street 1:10620 NW 29TH CT
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:754-368-9999
Practice Address - Fax:954-306-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12113310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility