Basic Information
Provider Information | |||||||||
NPI: | 1578589925 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PUNTA GORDA MEDICAL INVESTORS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIFE CARE CENTER OF PUNTA GORDA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3001 KEITH ST NW | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | TN | ||||||||
PostalCode: | 373123713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234735751 | ||||||||
FaxNumber: | 4233398344 | ||||||||
Practice Location | |||||||||
Address1: | 450 SHREVE ST | ||||||||
Address2: |   | ||||||||
City: | PUNTA GORDA | ||||||||
State: | FL | ||||||||
PostalCode: | 339503325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9416398771 | ||||||||
FaxNumber: | 9416393422 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2006 | ||||||||
LastUpdateDate: | 03/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CROSS | ||||||||
AuthorizedOfficialFirstName: | CINDY | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 4234735867 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF12940961 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0 311685-00 | 05 | FL |   | MEDICAID | 020550800 | 05 | FL |   | MEDICAID |