Provider Demographics
NPI:1609625284
Name:SEASIDE VILLA ASSISTED LIVING FACILITY LLC
Entity type:Organization
Organization Name:SEASIDE VILLA ASSISTED LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:RANEA
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-626-5321
Mailing Address - Street 1:610 PALM DRIVE
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937
Mailing Address - Country:US
Mailing Address - Phone:321-626-5321
Mailing Address - Fax:321-777-7545
Practice Address - Street 1:610 PALM DRIVE
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937
Practice Address - Country:US
Practice Address - Phone:321-626-5321
Practice Address - Fax:321-777-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home