Basic Information
| Provider Information | |||||||||
| NPI: | 1437139136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HQM OF MEADOWS SOUTH, LLC | ||||||||
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| OtherOrganizationName: | MEADOWS SOUTH CARE & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 PGA BLVD | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334102911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616270664 | ||||||||
| FaxNumber: | 5616272867 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 CRISTLAND RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402144150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023670104 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALCZAK | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5616270664 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100452 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12504247 | 05 | KY | MEDICAID |