Basic Information
| Provider Information | |||||||||
| NPI: | 1518959667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA DEPARTMENT OF VETERANS AFFAIRS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4419 TRAM RD | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324042559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507475401 | ||||||||
| FaxNumber: | 8507475301 | ||||||||
| Practice Location | |||||||||
| Address1: | 4419 TRAM RD | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324042559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507475401 | ||||||||
| FaxNumber: | 8507475301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PUCKETT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7275183202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | FL | X | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 314000000X | FL | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.