Provider Demographics
NPI:1053520809
Name:WILLOW HAVEN ALF, INC.
Entity type:Organization
Organization Name:WILLOW HAVEN ALF, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-653-3894
Mailing Address - Street 1:1220 NE 207TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2019
Mailing Address - Country:US
Mailing Address - Phone:305-653-3894
Mailing Address - Fax:
Practice Address - Street 1:1220 NE 207TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-2019
Practice Address - Country:US
Practice Address - Phone:305-653-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10457310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142152200Medicaid