Healthcare Provider Details

I. General information

NPI: 1114527744
Provider Name (Legal Business Name): SOMH BOCA RATON OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2020
Last Update Date: 11/01/2020
Certification Date: 11/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21865 PONDEROSA DR
BOCA RATON FL
33428-6215
US

IV. Provider business mailing address

21865 PONDEROSA DR
BOCA RATON FL
33428-6215
US

V. Phone/Fax

Practice location:
  • Phone: 561-571-7018
  • Fax: 561-482-5033
Mailing address:
  • Phone: 561-571-7018
  • Fax: 561-482-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY JAMES VAUGHN
Title or Position: REIMBURSEMENT ANALYST
Credential:
Phone: 240-595-6025