Provider Demographics
NPI:1447554910
Name:PLYMOUTH HOME FOR ADULTS, INC.
Entity type:Organization
Organization Name:PLYMOUTH HOME FOR ADULTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-384-5796
Mailing Address - Street 1:3225 PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-6099
Mailing Address - Country:US
Mailing Address - Phone:904-384-5796
Mailing Address - Fax:904-384-1061
Practice Address - Street 1:3225 PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6099
Practice Address - Country:US
Practice Address - Phone:904-384-5796
Practice Address - Fax:904-384-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5228310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140858500Medicaid