Provider Demographics
NPI:1295959815
Name:AMERICAN SENIOR LIVING OF SEBRING, FL, LLC
Entity type:Organization
Organization Name:AMERICAN SENIOR LIVING OF SEBRING, FL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEDERIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-385-5454
Mailing Address - Street 1:5959 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2075
Mailing Address - Country:US
Mailing Address - Phone:863-385-5454
Mailing Address - Fax:
Practice Address - Street 1:5959 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2075
Practice Address - Country:US
Practice Address - Phone:863-385-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5105310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686324800Medicaid
FL140900000Medicaid