1679984389 NPI number — EXTENDED CARE PORTFOLIO FLORIDA TENANT LLC

Table of content: (NPI 1679984389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679984389 NPI number — EXTENDED CARE PORTFOLIO FLORIDA TENANT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXTENDED CARE PORTFOLIO FLORIDA TENANT 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:
PACIFICA SENIOR LIVING FORT MYERS
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:
1679984389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 HANCOCK ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92110-2034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-296-9000
Provider Business Mailing Address Fax Number:
619-296-9090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9461 HEALTHPARK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-437-5511
Provider Business Practice Location Address Fax Number:
239-437-2826
Provider Enumeration Date:
05/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ISRANI
Authorized Official First Name:
DEPAK
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
619-296-9000

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9346 , 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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