1285990762 NPI number — ROSE OF SHARON GARDEN ALF

Table of content: (NPI 1285990762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285990762 NPI number — ROSE OF SHARON GARDEN ALF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE OF SHARON GARDEN ALF
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:
1285990762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8400 NW 28TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33322-2314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-747-0869
Provider Business Mailing Address Fax Number:
954-749-9644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8400 NW 28 ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-747-0869
Provider Business Practice Location Address Fax Number:
954-749-9644
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
MARLINE
Authorized Official Middle Name:
ROBERTS
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
954-821-7511

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  AL10291 , 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: 002673200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016195500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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