Provider Demographics
NPI:1316281215
Name:SELAH - FOREST LAKE MANOR, LLC
Entity type:Organization
Organization Name:SELAH - FOREST LAKE MANOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-543-1818
Mailing Address - Street 1:252 FOREST LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-8106
Mailing Address - Country:US
Mailing Address - Phone:386-760-7174
Mailing Address - Fax:386-760-7812
Practice Address - Street 1:252 FOREST LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-8106
Practice Address - Country:US
Practice Address - Phone:386-760-7174
Practice Address - Fax:386-760-7812
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELAH SENIORCARE II
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8869310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003453400Medicaid