Provider Demographics
NPI:1649863440
Name:YOUNG HEARTS EXTENDED ASSISTED LIVING FACILITY, LLC
Entity type:Organization
Organization Name:YOUNG HEARTS EXTENDED ASSISTED LIVING FACILITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-769-1122
Mailing Address - Street 1:1410 NE 219TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTEY
Mailing Address - State:FL
Mailing Address - Zip Code:32058-4387
Mailing Address - Country:US
Mailing Address - Phone:904-769-1122
Mailing Address - Fax:
Practice Address - Street 1:1410 NE 219TH ST
Practice Address - Street 2:
Practice Address - City:LAWTEY
Practice Address - State:FL
Practice Address - Zip Code:32058-4387
Practice Address - Country:US
Practice Address - Phone:904-769-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNG HEARTS EXTENDED ASSISTED LIVING FACILITY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-12
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty