Provider Demographics
NPI:1295905016
Name:WESLEY HOUSE ALF
Entity type:Organization
Organization Name:WESLEY HOUSE ALF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEYDE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER ADMIN
Authorized Official - Phone:813-469-4496
Mailing Address - Street 1:1146 TIMBER TRACE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543
Mailing Address - Country:US
Mailing Address - Phone:813-907-5565
Mailing Address - Fax:813-907-5565
Practice Address - Street 1:1146 TIMBER TRACE DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543
Practice Address - Country:US
Practice Address - Phone:813-907-5565
Practice Address - Fax:813-907-5565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESLEY HOUSE #2 ALF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10654310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140033900Medicaid
FL6817432OtherMEDICARE
FL681743296OtherMEDICARE
FL140033900OtherMEDICARE