1114304094 NPI number — TERRACES FACILITY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114304094 NPI number — TERRACES FACILITY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRACES FACILITY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TERRACES OF LAKE WORTH CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114304094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4302 HOLLYWOOD BLVD
Provider Second Line Business Mailing Address:
#369
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-6635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 6TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33460-4333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-586-0808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BLEICH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
845-641-8314

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1133096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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