Provider Demographics
NPI:1588961866
Name:JACOBS LADDER FAMILY II ASSISTED LIVING II
Entity type:Organization
Organization Name:JACOBS LADDER FAMILY II ASSISTED LIVING II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAROLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLERCQ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:321-223-3967
Mailing Address - Street 1:123 BOCA CIEGA RD
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2601
Mailing Address - Country:US
Mailing Address - Phone:321-613-2672
Mailing Address - Fax:
Practice Address - Street 1:123 BOCA CIEGA RD
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2601
Practice Address - Country:US
Practice Address - Phone:321-613-2672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11844310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility