Provider Demographics
NPI:1881882918
Name:MIDDLEBURG ASSISTED LIVING FACILITY, INC.
Entity type:Organization
Organization Name:MIDDLEBURG ASSISTED LIVING FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-291-1632
Mailing Address - Street 1:4192 CLOVE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6100
Mailing Address - Country:US
Mailing Address - Phone:904-673-1419
Mailing Address - Fax:
Practice Address - Street 1:4192 CLOVE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-6100
Practice Address - Country:US
Practice Address - Phone:904-673-1419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11083310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility