Provider Demographics
NPI:1770775413
Name:A BANYAN RESIDENCE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:A BANYAN RESIDENCE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-454-2345
Mailing Address - Street 1:3107 NE 40TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6413
Mailing Address - Country:US
Mailing Address - Phone:954-454-2345
Mailing Address - Fax:954-457-8242
Practice Address - Street 1:100 BASE AVE E
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3809
Practice Address - Country:US
Practice Address - Phone:941-412-4748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPPLIED FOR IT310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility