Basic Information
| Provider Information | |||||||||
| NPI: | 1215191440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7575 DR PHILLIPS BLVD | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328197216 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4760 JOG RD | ||||||||
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| City: | GREENACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334675119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614340434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | GARBERS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF HJ SIMS INVESTMENTS, LLC | ||||||||
| AuthorizedOfficialTelephone: | 4073634493 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HJ SIMS INVESTMENTS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.