Provider Demographics
NPI:1770029928
Name:KNOLLWOOD MANOR ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:KNOLLWOOD MANOR ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIGDALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-729-9679
Mailing Address - Street 1:1203 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-6244
Mailing Address - Country:US
Mailing Address - Phone:407-729-9679
Mailing Address - Fax:407-951-6698
Practice Address - Street 1:1203 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6244
Practice Address - Country:US
Practice Address - Phone:407-729-9679
Practice Address - Fax:407-951-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12576310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility