Healthcare Provider Details

I. General information

NPI: 1104011873
Provider Name (Legal Business Name): SENIOR CARE OF HIDDEN OAKS OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 HIDDEN TREE LANE
FORT MEYERS FL
33901-8388
US

IV. Provider business mailing address

1240 MARBELLA PLAZA DRIVE
TAMPA FL
33619-7906
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-1393
  • Fax: 239-939-1149
Mailing address:
  • Phone: 813-341-2700
  • Fax: 813-651-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5531
License Number StateFL

VIII. Authorized Official

Name: MR. R DANIEL VAUGHAN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 813-341-2700