| NPI | 1992189013 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LACEY HENDERSON Lpn 386-292-1097 |
| Organization Subpart ? | No |
| Primary Taxonomy | 311Z00000X Custodial Care Facility (Licence: FL pn 5213898) |
| Enumeration Date | 2015-07-18 |
| Last Update Date | 2015-07-18 |