Basic Information
Provider Information | |||||||||
NPI: | 1932103637 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SENIOR HEALTH-FIRST COAST, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FIRST COAST HEALTH & REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1675 PALM BEACH LAKES BLVD | ||||||||
Address2: | SUITE 900 | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 33401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6618017600 | ||||||||
FaxNumber: | 4143684213 | ||||||||
Practice Location | |||||||||
Address1: | 7723 JASPER AVE | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322117719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9047258044 | ||||||||
FaxNumber: | 9047213193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2005 | ||||||||
LastUpdateDate: | 10/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JAFFE | ||||||||
AuthorizedOfficialFirstName: | HOWARD | ||||||||
AuthorizedOfficialMiddleName: | DILLON | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2153466454 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1150096 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 022783800 | 05 | FL |   | MEDICAID |