Provider Demographics
NPI:1063939148
Name:HERON HOUSE ALF LLC
Entity type:Organization
Organization Name:HERON HOUSE ALF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ZEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-338-2999
Mailing Address - Street 1:2050 E BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 E BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-2321
Practice Address - Country:US
Practice Address - Phone:727-559-7776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10811310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL10811OtherAHCA