Provider Demographics
NPI:1831593383
Name:FREMONT ASSISTED LIVING
Entity type:Organization
Organization Name:FREMONT ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELUS
Authorized Official - Middle Name:GALLO
Authorized Official - Last Name:PANCHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-800-2653
Mailing Address - Street 1:2200 BAYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4213
Mailing Address - Country:US
Mailing Address - Phone:904-800-2653
Mailing Address - Fax:904-800-2656
Practice Address - Street 1:2200 BAYVIEW RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-4213
Practice Address - Country:US
Practice Address - Phone:904-800-2653
Practice Address - Fax:904-800-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12549310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility