Provider Demographics
NPI:1982910568
Name:ENON COUNTRY MANOR INC
Entity Type:Organization
Organization Name:ENON COUNTRY MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-327-4459
Mailing Address - Street 1:7701 ENON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32568-1531
Mailing Address - Country:US
Mailing Address - Phone:850-327-4459
Mailing Address - Fax:850-327-4724
Practice Address - Street 1:7701 ENON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILL
Practice Address - State:FL
Practice Address - Zip Code:32568-1531
Practice Address - Country:US
Practice Address - Phone:850-327-4459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 5153310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL5153Medicaid