Basic Information
| Provider Information | |||||||||
| NPI: | 1497120877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GV ENGLEWOOD, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND VILLA OF ENGLEWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 S RIVER RD | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342233909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13770 58TH ST N | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337603759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277263980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | FORTE | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 7277263980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL5501 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.