Provider Demographics
NPI:1053751693
Name:60TH AVENUE ALF, LLC
Entity type:Organization
Organization Name:60TH AVENUE ALF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:316-616-6288
Mailing Address - Street 1:8415 E 21ST ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2959
Mailing Address - Country:US
Mailing Address - Phone:316-616-6288
Mailing Address - Fax:316-616-6255
Practice Address - Street 1:2800 60TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-4324
Practice Address - Country:US
Practice Address - Phone:941-752-1990
Practice Address - Fax:941-752-1740
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUPITER TENANT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9932310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility