Basic Information
Provider Information | |||||||||
NPI: | 1487658985 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EDWARD J. HEALEY REHABILITATION AND NURSING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5616591270 | ||||||||
FaxNumber: | 5618426713 | ||||||||
Practice Location | |||||||||
Address1: | 5101 W. BLUE HERON BLVD. | ||||||||
Address2: |   | ||||||||
City: | RIVIERA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334187831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5618426111 | ||||||||
FaxNumber: | 5618426713 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 03/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | DARCY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5618045885 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NSF14030961 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 021203200 | 05 | FL |   | MEDICAID |