Provider Demographics
NPI:1053042150
Name:FRESH WATER AT HUDSON ALF, LLC
Entity type:Organization
Organization Name:FRESH WATER AT HUDSON ALF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:TO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-379-1746
Mailing Address - Street 1:11030 EVERGREEN WAY APT A302
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-4390
Mailing Address - Country:US
Mailing Address - Phone:253-655-7192
Mailing Address - Fax:
Practice Address - Street 1:14110 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1362
Practice Address - Country:US
Practice Address - Phone:253-655-7192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251J00000XAgenciesNursing Care