Provider Demographics
NPI:1700221959
Name:SUSIES HOME LLC
Entity Type:Organization
Organization Name:SUSIES HOME LLC
Other - Org Name:SUSIE'S HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUNICHI
Authorized Official - Middle Name:
Authorized Official - Last Name:OBAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-437-3131
Mailing Address - Street 1:28B KARAT PATH
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5670
Mailing Address - Country:US
Mailing Address - Phone:386-437-3131
Mailing Address - Fax:386-437-3131
Practice Address - Street 1:28B KARAT PATH
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5670
Practice Address - Country:US
Practice Address - Phone:386-437-3131
Practice Address - Fax:386-437-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12354310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility