Basic Information
Provider Information | |||||||||
NPI: | 1679984389 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EXTENDED CARE PORTFOLIO FLORIDA TENANT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PACIFICA SENIOR LIVING FORT MYERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1775 HANCOCK ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921102034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6192969000 | ||||||||
FaxNumber: | 6192969090 | ||||||||
Practice Location | |||||||||
Address1: | 9461 HEALTHPARK CIR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339083614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2394375511 | ||||||||
FaxNumber: | 2394372826 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2014 | ||||||||
LastUpdateDate: | 05/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ISRANI | ||||||||
AuthorizedOfficialFirstName: | DEPAK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6192969000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL9346 | FL | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.