Provider Demographics
NPI:1194140509
Name:SENIOR LIFE LLC
Entity type:Organization
Organization Name:SENIOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:II
Authorized Official - Credentials:JD, MBA
Authorized Official - Phone:813-267-7342
Mailing Address - Street 1:PO BOX 48857
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33646-0124
Mailing Address - Country:US
Mailing Address - Phone:813-319-0961
Mailing Address - Fax:
Practice Address - Street 1:619 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4786
Practice Address - Country:US
Practice Address - Phone:813-319-0961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility