Provider Demographics
NPI:1831489632
Name:SOUTHERN LIVE IN
Entity Type:Organization
Organization Name:SOUTHERN LIVE IN
Other - Org Name:SOUTHERN LIVE IN OF BRANDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESSETTE
Authorized Official - Suffix:
Authorized Official - Credentials:AMINISTRATOR
Authorized Official - Phone:813-655-0822
Mailing Address - Street 1:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-1005
Mailing Address - Country:US
Mailing Address - Phone:813-655-0822
Mailing Address - Fax:813-681-1482
Practice Address - Street 1:619 PRINCETON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7129
Practice Address - Country:US
Practice Address - Phone:813-655-0822
Practice Address - Fax:813-681-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9890310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility