Provider Demographics
NPI:1386353886
Name:RUSTIC RETREAT FLORIDA LLC
Entity type:Organization
Organization Name:RUSTIC RETREAT FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUFRIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-517-0055
Mailing Address - Street 1:3711 LONG BEACH BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3315
Mailing Address - Country:US
Mailing Address - Phone:562-517-0055
Mailing Address - Fax:
Practice Address - Street 1:1120 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-3229
Practice Address - Country:US
Practice Address - Phone:561-737-5881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility