Provider Demographics
NPI:1144876327
Name:IMMACULATE ADULT DAY CARE LLC
Entity type:Organization
Organization Name:IMMACULATE ADULT DAY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN,MSN
Authorized Official - Phone:321-631-9014
Mailing Address - Street 1:234 WILLARD ST STE A
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7984
Mailing Address - Country:US
Mailing Address - Phone:321-631-9014
Mailing Address - Fax:321-631-8010
Practice Address - Street 1:234 WILLARD ST STE A
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7984
Practice Address - Country:US
Practice Address - Phone:321-631-9014
Practice Address - Fax:321-631-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105066100Medicaid