Provider Demographics
NPI:1104327873
Name:LULA FRAZIER
Entity type:Organization
Organization Name:LULA FRAZIER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LULA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-460-3529
Mailing Address - Street 1:409 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-7109
Mailing Address - Country:US
Mailing Address - Phone:352-460-3529
Mailing Address - Fax:352-508-9798
Practice Address - Street 1:409 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-7109
Practice Address - Country:US
Practice Address - Phone:352-460-3529
Practice Address - Fax:352-508-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811354531Medicaid