Provider Demographics
NPI:1760885784
Name:HOUSE OF LIGHT SENIOR LIVING III
Entity Type:Organization
Organization Name:HOUSE OF LIGHT SENIOR LIVING III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIENE
Authorized Official - Middle Name:CORNETTA
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-368-5611
Mailing Address - Street 1:2306 WOODLAWN CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7645
Mailing Address - Country:US
Mailing Address - Phone:321-368-5611
Mailing Address - Fax:321-345-5925
Practice Address - Street 1:2306 WOODLAWN CIR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7645
Practice Address - Country:US
Practice Address - Phone:321-368-5611
Practice Address - Fax:321-345-5925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSE OF LIGHT SENIOR LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-04
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility