MEDICARE: EAGLERIDGE OPERATIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1700591138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLERIDGE OPERATIONS, LLC

Provider Business Mailing Address
First Line	:	10150 HIGHLAND MANOR DR STE 300
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-9712
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13881 EAGLE RIDGE DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-1866
Country	:	US
Telephone Number	:	239-561-7700
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	TRICIA THACKER
Credential	:
Telephone Number	:	813-558-6608

Provider Enumeration Date	:	01/19/2023
Last Update Date	:	01/19/2023

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