Provider Demographics
NPI:1922617505
Name:PALM COAST ALF MANAGEMENT LLC
Entity Type:Organization
Organization Name:PALM COAST ALF MANAGEMENT LLC
Other - Org Name:GOLD CHOICE PALM COAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DEETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-202-0046
Mailing Address - Street 1:269 KIPLING CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4124
Mailing Address - Country:US
Mailing Address - Phone:407-202-0046
Mailing Address - Fax:
Practice Address - Street 1:3830 OLD KINGS ROAD
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-307-5445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13591OtherASSISTED LIVING FACILITY LICENSE
FL110284500Medicaid