Provider Demographics
NPI:1881952844
Name:MYRTICE ANGELS SENIOR HOME CARE LLC.
Entity type:Organization
Organization Name:MYRTICE ANGELS SENIOR HOME CARE LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAFETA
Authorized Official - Middle Name:W
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-355-9737
Mailing Address - Street 1:1061 DIVISION ST.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209
Mailing Address - Country:US
Mailing Address - Phone:904-355-9737
Mailing Address - Fax:904-358-3933
Practice Address - Street 1:2570 VERNON ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-355-9737
Practice Address - Fax:904-358-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12117310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility