Healthcare Provider Details

I. General information

NPI: 1821758285
Provider Name (Legal Business Name): SANTA BARBARA SOCIAL CLUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 SANTA BARBARA BLVD STE 106-108
CAPE CORAL FL
33991-4359
US

IV. Provider business mailing address

9321 SW 174TH ST
PALMETTO BAY FL
33157-5716
US

V. Phone/Fax

Practice location:
  • Phone: 239-984-2916
  • Fax: 239-842-6787
Mailing address:
  • Phone: 786-479-2000
  • Fax: 239-842-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BORIS L. AVILA
Title or Position: PRESIDENT
Credential:
Phone: 786-479-2000