Provider Demographics
NPI:1720329063
Name:MORNINGSTAR ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:MORNINGSTAR ASSISTED LIVING, LLC
Other - Org Name:BAYTREE LAKESIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOICU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-920-9598
Mailing Address - Street 1:17920 GULF BLVD APT 703
Mailing Address - Street 2:
Mailing Address - City:REDINGTON SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1143
Mailing Address - Country:US
Mailing Address - Phone:360-920-9598
Mailing Address - Fax:727-914-0410
Practice Address - Street 1:6411 46TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-3105
Practice Address - Country:US
Practice Address - Phone:727-545-0623
Practice Address - Fax:727-544-2416
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORNINGSTAR ASSISTED LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-12
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6773310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008294100Medicaid