Healthcare Provider Details

I. General information

NPI: 1437659232
Provider Name (Legal Business Name): HSRE-AHR BONITA SPRINGS TRS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 LONGFELLOW LN
BONITA SPRINGS FL
34135-5963
US

IV. Provider business mailing address

11400 LONGFELLOW LN
BONITA SPRINGS FL
34135-5963
US

V. Phone/Fax

Practice location:
  • Phone: 239-301-4239
  • Fax: 239-301-0613
Mailing address:
  • Phone: 239-301-4239
  • Fax: 239-301-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL12672
License Number StateFL

VIII. Authorized Official

Name: EUGENE VALENTINE
Title or Position: ADMINISTRATOR
Credential:
Phone: 239-301-4239