Provider Demographics
NPI:1710154604
Name:JBA SVCS INC D/B/A IMMACULATE HOUSE AT COUNTRYSIDE
Entity Type:Organization
Organization Name:JBA SVCS INC D/B/A IMMACULATE HOUSE AT COUNTRYSIDE
Other - Org Name:FOREST HILLS HOME AT PALM HARBOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ALF ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCK-ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:AHCA ALF ADMIN
Authorized Official - Phone:727-934-4310
Mailing Address - Street 1:3823 PENDLEBURY DR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2670
Mailing Address - Country:US
Mailing Address - Phone:727-934-4310
Mailing Address - Fax:727-943-2075
Practice Address - Street 1:2542 COUNTRYSIDE PINES DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-4921
Practice Address - Country:US
Practice Address - Phone:727-934-4310
Practice Address - Fax:727-943-2075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JBA SVCS INC D/B/A FOREST HILLS HOME AT PALM HARBOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 11233310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility