Provider Demographics
NPI:1730338179
Name:TAVARES VILLAGE RETIREMENT COMMUNITY, LLC
Entity type:Organization
Organization Name:TAVARES VILLAGE RETIREMENT COMMUNITY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:407-454-9096
Mailing Address - Street 1:901 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2905
Mailing Address - Country:US
Mailing Address - Phone:407-454-9096
Mailing Address - Fax:407-843-0407
Practice Address - Street 1:1501 SUNSHINE PKWY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4496
Practice Address - Country:US
Practice Address - Phone:407-454-9096
Practice Address - Fax:407-843-0407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8948310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility