Provider Demographics
NPI:1740449263
Name:ANDRADA GUERZON #1 CORP
Entity type:Organization
Organization Name:ANDRADA GUERZON #1 CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-859-0475
Mailing Address - Street 1:815 W DAUGHTERY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-3121
Mailing Address - Country:US
Mailing Address - Phone:863-859-0475
Mailing Address - Fax:863-859-0865
Practice Address - Street 1:815 W DAUGHTERY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3121
Practice Address - Country:US
Practice Address - Phone:863-859-0475
Practice Address - Fax:863-859-0865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10535310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687427400Medicaid
FL142291000OtherACS