Provider Demographics
NPI:1972811339
Name:FOUR SEASONS ALF DBA SANFORD MANOR ALF
Entity Type:Organization
Organization Name:FOUR SEASONS ALF DBA SANFORD MANOR ALF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARVIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-322-3321
Mailing Address - Street 1:1704 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-2381
Mailing Address - Country:US
Mailing Address - Phone:407-322-3321
Mailing Address - Fax:407-322-3324
Practice Address - Street 1:1704 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2381
Practice Address - Country:US
Practice Address - Phone:407-322-3321
Practice Address - Fax:407-322-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL47893104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000390200Medicaid
FL000390700Medicaid