Provider Demographics
NPI:1538594577
Name:SELAH-GULF BREEZE COURTYARD, LLC
Entity type:Organization
Organization Name:SELAH-GULF BREEZE COURTYARD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-543-1818
Mailing Address - Street 1:3428 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-1400
Mailing Address - Country:US
Mailing Address - Phone:850-934-1662
Mailing Address - Fax:850-934-4218
Practice Address - Street 1:3428 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-1400
Practice Address - Country:US
Practice Address - Phone:850-934-1662
Practice Address - Fax:850-934-4218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELAH SENIORCARE II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9976310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7618OtherWORLDNET - MEDICAID DIVERSION PROGRAM
FL003102500OtherMEDICAID WAIVER PROGRAM
FL109168OtherAMERICAN ELDERCARE - MEDICAID DIVERSION PROGRAM