Provider Demographics
NPI:1134550718
Name:LOVELY CARE MANOR LLC
Entity type:Organization
Organization Name:LOVELY CARE MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHOUTHAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-754-5309
Mailing Address - Street 1:2869 SARAH DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2869 SARAH DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2010
Practice Address - Country:US
Practice Address - Phone:727-754-5309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12322310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008879500Medicaid