Provider Demographics
NPI:1760967590
Name:ANGEL OF LIGHT ASSISTED LIVING FACILITY, LLC
Entity Type:Organization
Organization Name:ANGEL OF LIGHT ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ISOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-501-0144
Mailing Address - Street 1:613 SW HOMELAND RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6263
Mailing Address - Country:US
Mailing Address - Phone:772-353-5885
Mailing Address - Fax:
Practice Address - Street 1:613 SW HOMELAND RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6263
Practice Address - Country:US
Practice Address - Phone:772-353-5885
Practice Address - Fax:772-353-5890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility