Provider Demographics
NPI:1891198842
Name:ANGEL'S SENIOR LIVING ASSISTED LIVING FACILITY LLC
Entity type:Organization
Organization Name:ANGEL'S SENIOR LIVING ASSISTED LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CARLYLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:386-527-5918
Mailing Address - Street 1:524 FRED GAMBLE WAY
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7026
Mailing Address - Country:US
Mailing Address - Phone:386-527-5918
Mailing Address - Fax:386-677-4249
Practice Address - Street 1:524 FRED GAMBLE WAY
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7026
Practice Address - Country:US
Practice Address - Phone:386-527-5918
Practice Address - Fax:386-677-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12555310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility