Provider Demographics
NPI:1255573630
Name:VILLA OF KINGS & QUEENS OF DELRAY INC.
Entity type:Organization
Organization Name:VILLA OF KINGS & QUEENS OF DELRAY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-450-8551
Mailing Address - Street 1:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10185-0581
Mailing Address - Country:US
Mailing Address - Phone:561-450-8551
Mailing Address - Fax:561-498-3870
Practice Address - Street 1:13415 BARWICK RD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-1209
Practice Address - Country:US
Practice Address - Phone:561-450-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11308310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000089300Medicaid