Provider Demographics
NPI:1114698255
Name:NOKOMIS ASSISTED LIVING
Entity type:Organization
Organization Name:NOKOMIS ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-401-7109
Mailing Address - Street 1:1116 PIEDMONT AVE NE APT 6
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5010
Mailing Address - Country:US
Mailing Address - Phone:412-401-7109
Mailing Address - Fax:
Practice Address - Street 1:336 MONET DR
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-1357
Practice Address - Country:US
Practice Address - Phone:412-401-7109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRUCE-LAMPLEY HOMES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251G00000XAgenciesHospice Care, Community Based
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient