Basic Information
| Provider Information | |||||||||
| NPI: | 1720002819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAMILTON HEALTH ENTERPRISES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUWANNEE VALLEY NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 NW 15TH AVE | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320525874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867921868 | ||||||||
| FaxNumber: | 3867926839 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 NW 15TH AVE | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320525874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867921868 | ||||||||
| FaxNumber: | 3867926839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3867921868 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | TREASURER | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1546096 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 020630000 | 05 | FL | MEDICAID |