1265849830 NPI number — SKILLED NURSING CARE MEDICAL GROUP LLC

Table of content: (NPI 1265849830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265849830 NPI number — SKILLED NURSING CARE MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKILLED NURSING CARE MEDICAL GROUP LLC
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:
Provider Other Organization Name Type Code:
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:
1265849830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2335 AARON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-5305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-670-7400
Provider Business Practice Location Address Fax Number:
855-674-7401
Provider Enumeration Date:
07/16/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOENINGER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
855-674-7400

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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