Basic Information
| Provider Information | |||||||||
| NPI: | 1649399577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESC NEW PORT RICHEY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMERITUS AT FORT MYERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1896 PARK MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399395421 | ||||||||
| FaxNumber: | 2399394751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MEDICAID SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2062982909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL 5096 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 686854100 | 05 | FL | MEDICAID |