Basic Information
Provider Information | |||||||||
NPI: | 1982605085 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OKEECHOBEE COUNCIL ON AGING INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GLADES HEALTH CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1311 SW 16TH ST | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326081128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523768821 | ||||||||
FaxNumber: | 3523763654 | ||||||||
Practice Location | |||||||||
Address1: | 230 S BARFIELD HWY | ||||||||
Address2: |   | ||||||||
City: | PAHOKEE | ||||||||
State: | FL | ||||||||
PostalCode: | 334761834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619245561 | ||||||||
FaxNumber: | 5619249466 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2005 | ||||||||
LastUpdateDate: | 01/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HURT | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3523768821 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1172096 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 020320300 | 05 | FL |   | MEDICAID |