Healthcare Provider Details

I. General information

NPI: 1881681724
Provider Name (Legal Business Name): SHADY REST CARE PAVILION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N AIRPORT RD
FORT MYERS FL
33907-1426
US

IV. Provider business mailing address

2310 N AIRPORT RD
FORT MYERS FL
33907-1426
US

V. Phone/Fax

Practice location:
  • Phone: 239-931-8401
  • Fax: 239-931-8453
Mailing address:
  • Phone: 239-931-8401
  • Fax: 239-931-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1497096
License Number StateFL

VIII. Authorized Official

Name: MR. WESTON R EDWARDS
Title or Position: CEO
Credential:
Phone: 239-931-8402