Healthcare Provider Details

I. General information

NPI: 1497702054
Provider Name (Legal Business Name): HEARTLAND OF BROOKSVILLE FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 LAMAR AVE
BROOKSVILLE FL
34601-3228
US

IV. Provider business mailing address

333 N SUMMIT ST
TOLEDO OH
43604-2615
US

V. Phone/Fax

Practice location:
  • Phone: 352-799-2226
  • Fax: 352-799-3368
Mailing address:
  • Phone: 419-252-5500
  • Fax: 877-385-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1213096
License Number StateFL

VIII. Authorized Official

Name: MR. MARTIN D ALLEN
Title or Position: DIRECTOR
Credential:
Phone: 419-252-5734