Healthcare Provider Details

I. General information

NPI: 1649462359
Provider Name (Legal Business Name): VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 MASON AVE EMORY L BENNETT VA NURSING HOME
DAYTONA BEACH FL
32117-5103
US

IV. Provider business mailing address

16840 SE 52ND PL
OCKLAWAHA FL
32179-2836
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-3460
  • Fax:
Mailing address:
  • Phone: 386-916-6755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberRN2047752
License Number StateFL

VIII. Authorized Official

Name: MISS PATRICIA RENEE ANDERSON
Title or Position: RN
Credential:
Phone: 386-916-6755