Provider Demographics
NPI:1669993499
Name:RONNY'S ASSISTED LIVING LLC
Entity type:Organization
Organization Name:RONNY'S ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YAINES
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-449-3877
Mailing Address - Street 1:2903 W SAINT CONRAD ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2922
Mailing Address - Country:US
Mailing Address - Phone:813-449-3877
Mailing Address - Fax:844-633-5300
Practice Address - Street 1:8016 DELL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4621
Practice Address - Country:US
Practice Address - Phone:813-449-3877
Practice Address - Fax:844-633-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-01
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL13116310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023553100Medicaid