Provider Demographics
NPI:1083030522
Name:BALMY BEACH ALF OF FLORIDA INC
Entity type:Organization
Organization Name:BALMY BEACH ALF OF FLORIDA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:4073-405-1047
Mailing Address - Street 1:849 WOOD BRIAR LOOP
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5434
Mailing Address - Country:US
Mailing Address - Phone:407-405-1047
Mailing Address - Fax:407-322-8226
Practice Address - Street 1:1030 BALMY BEACH DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5902
Practice Address - Country:US
Practice Address - Phone:407-405-1047
Practice Address - Fax:407-322-8226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8705310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL8705OtherAHCA