Healthcare Provider Details

I. General information

NPI: 1376741124
Provider Name (Legal Business Name): INDIGO PALMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1494
US

IV. Provider business mailing address

570 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1494
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-3333
  • Fax: 386-238-3414
Mailing address:
  • Phone: 386-238-3333
  • Fax: 386-238-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9261
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL9261
License Number StateFL

VIII. Authorized Official

Name: MR. PAUL JAMESON MARSH MITCHELL I
Title or Position: ADMINISTRATOR
Credential: CALA
Phone: 386-238-3333