Provider Demographics
NPI:1548635790
Name:PELICAN PALACE, LLC
Entity type:Organization
Organization Name:PELICAN PALACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:954-709-6545
Mailing Address - Street 1:12335 NW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3446
Mailing Address - Country:US
Mailing Address - Phone:954-709-6545
Mailing Address - Fax:954-369-4742
Practice Address - Street 1:12335 NW 51ST ST
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3446
Practice Address - Country:US
Practice Address - Phone:954-709-6545
Practice Address - Fax:954-369-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-13
Last Update Date:2015-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLMedicaid