Provider Demographics
NPI:1972775203
Name:WESLEY HOUSE ALF #3
Entity type:Organization
Organization Name:WESLEY HOUSE ALF #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEYEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-469-4496
Mailing Address - Street 1:28502 TALL GRASS DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5829
Mailing Address - Country:US
Mailing Address - Phone:813-991-4133
Mailing Address - Fax:
Practice Address - Street 1:28502 TALL GRASS DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5829
Practice Address - Country:US
Practice Address - Phone:813-991-5071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESLEY HOUSE ALF #3
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-27
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11126310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681743296OtherWAIVERS RES HABILITATION
FL140033900Medicaid