Provider Demographics
NPI:1457894586
Name:STATE ROAD 121
Entity type:Organization
Organization Name:STATE ROAD 121
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-474-2696
Mailing Address - Street 1:2518 BURNSED BLVD
Mailing Address - Street 2:SUITE 317
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32163-2704
Mailing Address - Country:US
Mailing Address - Phone:352-474-2696
Mailing Address - Fax:352-464-6046
Practice Address - Street 1:2518 BURNSED BLVD
Practice Address - Street 2:SUITE 317
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2704
Practice Address - Country:US
Practice Address - Phone:352-474-2696
Practice Address - Fax:352-464-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility