Provider Demographics
NPI:1285068908
Name:SAMSON VILLA OF ORANGE PARK
Entity type:Organization
Organization Name:SAMSON VILLA OF ORANGE PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:CORBETT
Authorized Official - Last Name:GRANGER II
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-755-8707
Mailing Address - Street 1:2757 PEBBLERIDGE COURT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2757 PEBBLERIDGE CT
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-6261
Practice Address - Country:US
Practice Address - Phone:904-375-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12338310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility