1356540033 NPI number — SNELL ISLAND SNF LLC

Table of content: (NPI 1356540033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356540033 NPI number — SNELL ISLAND SNF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNELL ISLAND SNF 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:
SHORE ACRES REHABILITATION AND HEALTH 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:
1356540033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 NE MIAMI GARDENS DR
Provider Second Line Business Mailing Address:
#368
Provider Business Mailing Address City Name:
NORTH MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33179-5035
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:
4500 INDIANAPOLIS ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33703-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-209-4600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOGOMILSKY
Authorized Official First Name:
TZVI
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
305-401-7901

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1499095 , 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)

  • Identifier: 032413200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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