Provider Demographics
NPI:1780194258
Name:FAVOR MEMORYCARE ASSISTED LIVING FACILITY INC
Entity Type:Organization
Organization Name:FAVOR MEMORYCARE ASSISTED LIVING FACILITY INC
Other - Org Name:FAVOR MEMORYCARE ASSISTED LIVING FACILITY INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ETOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-415-5064
Mailing Address - Street 1:385 E WILDMERE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5537
Mailing Address - Country:US
Mailing Address - Phone:407-951-6926
Mailing Address - Fax:
Practice Address - Street 1:385 E WILDMERE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5537
Practice Address - Country:US
Practice Address - Phone:407-951-6926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13066310400000X
FL13066310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720418635Medicaid