Basic Information
Provider Information
NPI: 1275666273
EntityType: 2
ReplacementNPI:  
OrganizationName: HCR MANOR CARE SERVICES OF FLORIDA, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: PROMEDICA HOSPICE (JACKSONVILLE)
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 333 N SUMMIT ST
Address2: ATTN DEAN SHIPMAN
City: TOLEDO
State: OH
PostalCode: 436042615
CountryCode: US
TelephoneNumber: 4192547851
FaxNumber:  
Practice Location
Address1: 8130 BAYMEADOWS WAY W
Address2: SUITE 201
City: JACKSONVILLE
State: FL
PostalCode: 322567451
CountryCode: US
TelephoneNumber: 9047342553
FaxNumber: 9047372631
Other Information
ProviderEnumerationDate: 03/13/2007
LastUpdateDate: 01/31/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ALLEN
AuthorizedOfficialFirstName: MARTIN
AuthorizedOfficialMiddleName: D
AuthorizedOfficialTitleorPosition: DIRECTOR
AuthorizedOfficialTelephone: 4192525734
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/31/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251G00000X  Y AgenciesHospice Care, Community Based 

ID Information
IDTypeStateIssuerDescription
00014180005FL MEDICAID


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