Provider Demographics
NPI:1952720294
Name:ALLIANCE FOUNDATION OF FLORIDA INC
Entity Type:Organization
Organization Name:ALLIANCE FOUNDATION OF FLORIDA INC
Other - Org Name:INDIGO MANOR ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KERNON
Authorized Official - Suffix:II
Authorized Official - Credentials:NHA
Authorized Official - Phone:386-547-4686
Mailing Address - Street 1:595 N WILLIAMSON BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-7185
Mailing Address - Country:US
Mailing Address - Phone:386-257-4400
Mailing Address - Fax:386-257-4372
Practice Address - Street 1:595 N WILLIAMSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-7185
Practice Address - Country:US
Practice Address - Phone:386-257-4400
Practice Address - Fax:386-257-4372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCE FOUNDATION OF FLORIDA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5400310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL5400OtherSTATE OF FLORIDA AHCA