Provider Demographics
NPI:1669759015
Name:AT HOME CARE ASSISTED LIVING FACILITY, INC.
Entity type:Organization
Organization Name:AT HOME CARE ASSISTED LIVING FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:LATOYA
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-948-0723
Mailing Address - Street 1:42042 CHINABERRY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-8358
Mailing Address - Country:US
Mailing Address - Phone:407-948-0723
Mailing Address - Fax:321-256-5193
Practice Address - Street 1:42042 CHINABERRY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32736-8358
Practice Address - Country:US
Practice Address - Phone:407-948-0723
Practice Address - Fax:321-256-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)