Provider Demographics
NPI:1366576837
Name:DELAND SENIOR CARE, LLC
Entity type:Organization
Organization Name:DELAND SENIOR CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:317-514-5985
Mailing Address - Street 1:130 W ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-5861
Mailing Address - Country:US
Mailing Address - Phone:386-734-6401
Mailing Address - Fax:386-734-9168
Practice Address - Street 1:130 W ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5861
Practice Address - Country:US
Practice Address - Phone:386-734-6401
Practice Address - Fax:386-734-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL89310400000X
FLSNF10080961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020278900Medicaid
FL679337100Medicaid
FL141178100Medicaid
FL020278900Medicaid