Provider Demographics
NPI:1295171445
Name:LIVE OAK MANOR ASSISTED LIVING FACILITY
Entity type:Organization
Organization Name:LIVE OAK MANOR ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LENNON-JOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-377-2868
Mailing Address - Street 1:5660 MAUNA LOA BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8930
Mailing Address - Country:US
Mailing Address - Phone:941-377-2868
Mailing Address - Fax:941-377-8824
Practice Address - Street 1:5660 MAUNA LOA BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-8930
Practice Address - Country:US
Practice Address - Phone:941-377-2868
Practice Address - Fax:941-377-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6039310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility