Healthcare Provider Details

I. General information

NPI: 1205088986
Provider Name (Legal Business Name): JUNIPER VILLAGE EVENTIDE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 VICEROY CT
CAPE CORAL FL
33904-9048
US

IV. Provider business mailing address

4920 VICEROY CT
CAPE CORAL FL
33904-9048
US

V. Phone/Fax

Practice location:
  • Phone: 239-542-3121
  • Fax:
Mailing address:
  • Phone: 239-542-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0007753
License Number StateFL

VIII. Authorized Official

Name: MRS. MARGARET PEPPER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 239-542-3121