Healthcare Provider Details

I. General information

NPI: 1700239563
Provider Name (Legal Business Name): GV DEERFIELD BEACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SW 24TH AVE
DEERFIELD BEACH FL
33442-7601
US

IV. Provider business mailing address

13770 58TH ST N SUITE 312
CLEARWATER FL
33760-3759
US

V. Phone/Fax

Practice location:
  • Phone: 954-360-7667
  • Fax: 954-360-7363
Mailing address:
  • Phone: 727-726-3980
  • Fax: 727-726-5345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL# 8697
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL# 8697
License Number StateFL

VIII. Authorized Official

Name: JOHNNY SIZEMORE
Title or Position: OPERATIONS COORDINATOR
Credential:
Phone: 727-726-3980