Provider Demographics
NPI:1972972099
Name:SENIOR CARE LIVINGIV LLC
Entity Type:Organization
Organization Name:SENIOR CARE LIVINGIV LLC
Other - Org Name:INSPIRED LIVING AT PALM BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOULDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-592-8889
Mailing Address - Street 1:350 MALABAR RD SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2947
Mailing Address - Country:US
Mailing Address - Phone:321-574-6290
Mailing Address - Fax:
Practice Address - Street 1:350 MALABAR RD SW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2947
Practice Address - Country:US
Practice Address - Phone:321-574-6290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12617311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)