Provider Demographics
NPI:1215470216
Name:INNOVATE ASSISTED LIVING FACILITY
Entity type:Organization
Organization Name:INNOVATE ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:305-321-1904
Mailing Address - Street 1:5586 SE COLLINS AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-8062
Mailing Address - Country:US
Mailing Address - Phone:305-321-1904
Mailing Address - Fax:
Practice Address - Street 1:5586 SE COLLINS AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-8062
Practice Address - Country:US
Practice Address - Phone:305-321-1904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12885310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility