Basic Information
| Provider Information | |||||||||
| NPI: | 1093786667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | A.G. HOLLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1199 W LANTANA RD | ||||||||
| Address2: | |||||||||
| City: | LANTANA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334621514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615825666 | ||||||||
| FaxNumber: | 5615403788 | ||||||||
| Practice Location | |||||||||
| Address1: | 1199 W LANTANA RD | ||||||||
| Address2: | |||||||||
| City: | LANTANA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334621514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615825666 | ||||||||
| FaxNumber: | 5615403788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 03/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL ADMIN. SERVICES COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5615403377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 281P00000X | 3979 | FL | Y | Hospitals | Chronic Disease Hospital |
No ID Information.