Basic Information
| Provider Information | |||||||||
| NPI: | 1790730463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAPITAL HEALTH CARE ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAPITAL HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 CAPITAL MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508774115 | ||||||||
| FaxNumber: | 8508772828 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 CAPITAL MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508774115 | ||||||||
| FaxNumber: | 8508772828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | GAMEL | ||||||||
| AuthorizedOfficialFirstName: | GWENDOLYN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8508774115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1073C96 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 025209300 | 05 | FL | MEDICAID |