Healthcare Provider Details

I. General information

NPI: 1205881646
Provider Name (Legal Business Name): NORTHPORT HEALTH SERVICES OF FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 3RD ST
DAYTONA BEACH FL
32117-4101
US

IV. Provider business mailing address

1055 3RD ST
DAYTONA BEACH FL
32117-4101
US

V. Phone/Fax

Practice location:
  • Phone: 386-252-3686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF11210961
License Number StateFL

VIII. Authorized Official

Name: PHILLIP CODY LONG
Title or Position: CFO
Credential:
Phone: 205-391-3600