Provider Demographics
NPI:1851510598
Name:AMERICAN SENIOR LIVING OF DADE CITY FL LLC
Entity Type:Organization
Organization Name:AMERICAN SENIOR LIVING OF DADE CITY FL LLC
Other - Org Name:EDWINOLA RETIREMENT COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MIS
Authorized Official - Prefix:MS
Authorized Official - First Name:DORENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-963-3400
Mailing Address - Street 1:5692 STRAND CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-3389
Mailing Address - Country:US
Mailing Address - Phone:239-963-3400
Mailing Address - Fax:239-963-3401
Practice Address - Street 1:14235 EDWINOLA WAY
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-3763
Practice Address - Country:US
Practice Address - Phone:352-567-6500
Practice Address - Fax:352-567-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7295310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140899200Medicaid
FL686252700Medicaid