Provider Demographics
NPI:1770742231
Name:EVERLASTING GRACE ASSISTED LIVING INC.
Entity type:Organization
Organization Name:EVERLASTING GRACE ASSISTED LIVING INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PIER
Authorized Official - Middle Name:
Authorized Official - Last Name:GASMENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-595-7353
Mailing Address - Street 1:747 BON AIR ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4631
Mailing Address - Country:US
Mailing Address - Phone:863-688-1196
Mailing Address - Fax:863-687-7707
Practice Address - Street 1:1325 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-1117
Practice Address - Country:US
Practice Address - Phone:727-823-6812
Practice Address - Fax:727-822-2334
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
FLAL # 51953104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142552800Medicaid