Provider Demographics
NPI:1932543782
Name:CORAL SPRINGS COUNTRY CLUB FOR SENIORS, INC.
Entity type:Organization
Organization Name:CORAL SPRINGS COUNTRY CLUB FOR SENIORS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETRINEA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/HCM
Authorized Official - Phone:954-839-4791
Mailing Address - Street 1:2903 NW 115TH TER
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3439
Mailing Address - Country:US
Mailing Address - Phone:954-839-4791
Mailing Address - Fax:
Practice Address - Street 1:2903 NW 115TH TER
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3439
Practice Address - Country:US
Practice Address - Phone:954-839-4791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10582310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility