Provider Demographics
NPI:1780825489
Name:EXCELSIOR OMEGA INC.
Entity Type:Organization
Organization Name:EXCELSIOR OMEGA INC.
Other - Org Name:BRISIANA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAIDE ELIGIBLE
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ST JUSTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-371-4096
Mailing Address - Street 1:15 DADE AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1608
Mailing Address - Country:US
Mailing Address - Phone:941-371-4091
Mailing Address - Fax:
Practice Address - Street 1:15 DADE AVE
Practice Address - Street 2:16 ST LUCIE AVE
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-1608
Practice Address - Country:US
Practice Address - Phone:941-371-4091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11449310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility