Provider Demographics
NPI:1942436563
Name:RIVER RETREATS INC. DBA HARBOR BREEZE SENIOR LIVING
Entity Type:Organization
Organization Name:RIVER RETREATS INC. DBA HARBOR BREEZE SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-697-2886
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:312 N.W. AVE. D
Mailing Address - City:CARRABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:32322-0612
Mailing Address - Country:US
Mailing Address - Phone:850-697-2886
Mailing Address - Fax:850-697-3046
Practice Address - Street 1:312 N.W . AVENUE D
Practice Address - Street 2:
Practice Address - City:CARRABELLE
Practice Address - State:FL
Practice Address - Zip Code:32322-0612
Practice Address - Country:US
Practice Address - Phone:850-697-2886
Practice Address - Fax:850-697-3046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7798310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676935700Medicaid