Provider Demographics
NPI:1013489962
Name:BOSWELL MANOR LLC
Entity Type:Organization
Organization Name:BOSWELL MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-768-9026
Mailing Address - Street 1:2185 HIGHWAY 173
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-5705
Mailing Address - Country:US
Mailing Address - Phone:850-768-9026
Mailing Address - Fax:
Practice Address - Street 1:2185 HIGHWAY 173
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-5705
Practice Address - Country:US
Practice Address - Phone:850-768-9026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100834700Medicaid