Provider Demographics
NPI:1104269026
Name:BAXTER'S ADULT LIVING FACILITY. INC
Entity type:Organization
Organization Name:BAXTER'S ADULT LIVING FACILITY. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRELANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-871-7865
Mailing Address - Street 1:1092 SW MAJORCA AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953
Mailing Address - Country:US
Mailing Address - Phone:772-871-7865
Mailing Address - Fax:772-871-7988
Practice Address - Street 1:1092 SW MAJORCA AVENUE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-871-7865
Practice Address - Fax:772-871-7988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11666310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001599100Medicaid