Provider Demographics
NPI:1043040249
Name:PRIDE TRIBE INC.
Entity type:Organization
Organization Name:PRIDE TRIBE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GAYLORD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:561-541-3700
Mailing Address - Street 1:716 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-4304
Mailing Address - Country:US
Mailing Address - Phone:561-541-3700
Mailing Address - Fax:
Practice Address - Street 1:716 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-4304
Practice Address - Country:US
Practice Address - Phone:561-541-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-03
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1700662376Medicaid