Provider Demographics
NPI:1285165233
Name:SPRUCE CREEK ASSISTED LIVING ,LLC
Entity type:Organization
Organization Name:SPRUCE CREEK ASSISTED LIVING ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-310-9405
Mailing Address - Street 1:5953 BROKEN BOW LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7581
Mailing Address - Country:US
Mailing Address - Phone:386-872-6155
Mailing Address - Fax:
Practice Address - Street 1:762 COBBLESTONE WAY
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1026
Practice Address - Country:US
Practice Address - Phone:407-310-9405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12422310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility