Provider Demographics
NPI:1528686672
Name:CHRISTALLIS MANOR II LLC
Entity type:Organization
Organization Name:CHRISTALLIS MANOR II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMPARO
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIERKING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-274-5573
Mailing Address - Street 1:819 N 31ST CT
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6111
Mailing Address - Country:US
Mailing Address - Phone:954-274-5573
Mailing Address - Fax:
Practice Address - Street 1:819 N 31ST CT
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6111
Practice Address - Country:US
Practice Address - Phone:954-274-5573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107176600Medicaid