Provider Demographics
NPI:1962139493
Name:PRESTIGE PLACE ALF LLC
Entity type:Organization
Organization Name:PRESTIGE PLACE ALF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KOREN
Authorized Official - Middle Name:NATALIE
Authorized Official - Last Name:MCKENZIE-JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-632-5788
Mailing Address - Street 1:3900 NW 23RD PL
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-2266
Mailing Address - Country:US
Mailing Address - Phone:954-632-5788
Mailing Address - Fax:
Practice Address - Street 1:256 BARBAROSSA RD NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1809
Practice Address - Country:US
Practice Address - Phone:954-632-5788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility