Provider Demographics
NPI:1194135525
Name:FLORIDA ASSISTANT LIVING ORGANIZATION, LLC
Entity type:Organization
Organization Name:FLORIDA ASSISTANT LIVING ORGANIZATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-973-2348
Mailing Address - Street 1:458 NW MARION ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-1431
Mailing Address - Country:US
Mailing Address - Phone:850-973-2348
Mailing Address - Fax:
Practice Address - Street 1:219 SE ABERNATHY WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-7044
Practice Address - Country:US
Practice Address - Phone:850-973-2415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12141310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003217203Medicaid