Basic Information
| Provider Information | |||||||||
| NPI: | 1538252721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLA MARIA NURSING & REHABILITATION CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. CATHERINE'S REHABILITATION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 NE 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547396233 | ||||||||
| FaxNumber: | 9547331532 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 NE 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547396233 | ||||||||
| FaxNumber: | 9547331532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR HOSPITAL OPERATIO | ||||||||
| AuthorizedOfficialTelephone: | 3053571735 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | FL 4262 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 283X00000X | 4262 | FL | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 012002200 | 05 | FL | MEDICAID |