Provider Demographics
NPI:1831448174
Name:HOUSE OF LIGHT SENIOR LIVING, LLC
Entity type:Organization
Organization Name:HOUSE OF LIGHT SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIENE
Authorized Official - Middle Name:CORNETTA
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-368-5611
Mailing Address - Street 1:2638 JUPITER BLVD SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-3565
Mailing Address - Country:US
Mailing Address - Phone:321-368-5611
Mailing Address - Fax:321-345-5925
Practice Address - Street 1:2638 JUPITER BLVD SW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32908-3565
Practice Address - Country:US
Practice Address - Phone:321-368-5611
Practice Address - Fax:321-345-5925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12240310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility