Provider Demographics
NPI:1790294742
Name:DELAND MANOR ASSISTED LIVING CORP
Entity Type:Organization
Organization Name:DELAND MANOR ASSISTED LIVING CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:FABIAN
Authorized Official - Last Name:JAVIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-453-6541
Mailing Address - Street 1:245 S AMELIA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-5913
Mailing Address - Country:US
Mailing Address - Phone:386-624-7777
Mailing Address - Fax:386-279-7341
Practice Address - Street 1:245 S. AMELIA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724
Practice Address - Country:US
Practice Address - Phone:386-624-7777
Practice Address - Fax:386-279-7341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12944310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility