Basic Information
| Provider Information | |||||||||
| NPI: | 1154867547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GVDB OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GVDB OPERATIONS, LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13770 58TH ST N | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
| FaxNumber: | 7277265345 | ||||||||
| Practice Location | |||||||||
| Address1: | 14555 SIMS RD | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614961111 | ||||||||
| FaxNumber: | 5616379990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCINTOSH | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3525622668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL5113 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.