Healthcare Provider Details

I. General information

NPI: 1649399577
Provider Name (Legal Business Name): ESC NEW PORT RICHEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 PARK MEADOWS DR
FORT MYERS FL
33907-3738
US

IV. Provider business mailing address

3131 ELLIOTT AVE SUITE 500
SEATTLE WA
98121-1044
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-5421
  • Fax: 239-939-4751
Mailing address:
  • Phone: 206-298-2909
  • Fax: 206-301-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL 5096
License Number StateFL

VIII. Authorized Official

Name: TRACY ALLEN
Title or Position: DIRECTOR OF MEDICAID SERVICES
Credential:
Phone: 206-298-2909