Provider Demographics
NPI:1942630462
Name:1001 OLD TOMOKA LLC
Entity Type:Organization
Organization Name:1001 OLD TOMOKA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:OFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-453-1519
Mailing Address - Street 1:1001 OLD TOMOKA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5979
Mailing Address - Country:US
Mailing Address - Phone:386-453-1519
Mailing Address - Fax:888-562-7611
Practice Address - Street 1:1001 OLD TOMOKA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5979
Practice Address - Country:US
Practice Address - Phone:386-453-1519
Practice Address - Fax:888-562-7611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12175310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility