Provider Demographics
NPI:1750548475
Name:ADULT HEALTHCARE CORP
Entity type:Organization
Organization Name:ADULT HEALTHCARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDER
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-387-1830
Mailing Address - Street 1:12980 SW HIGHWAY 484
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6428
Mailing Address - Country:US
Mailing Address - Phone:352-387-1830
Mailing Address - Fax:352-873-0237
Practice Address - Street 1:1731 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8179
Practice Address - Country:US
Practice Address - Phone:352-387-1830
Practice Address - Fax:352-873-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7687310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14396501Medicaid