Provider Demographics
NPI:1356407704
Name:BREAKWATER ADULT FAMILY CARE HOME LLC
Entity type:Organization
Organization Name:BREAKWATER ADULT FAMILY CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-598-0288
Mailing Address - Street 1:22699 SW BREAKWATER BLVD
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-4039
Mailing Address - Country:US
Mailing Address - Phone:352-401-7699
Mailing Address - Fax:352-401-7698
Practice Address - Street 1:22699 SW BREAKWATER BLVD
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-4039
Practice Address - Country:US
Practice Address - Phone:352-401-7699
Practice Address - Fax:352-401-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905655320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities