Healthcare Provider Details

I. General information

NPI: 1093140055
Provider Name (Legal Business Name): PALM GARDEN OF GAINESVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 SW 62ND BLVD
GAINESVILLE FL
32607-2084
US

IV. Provider business mailing address

2033 MAIN ST SUITE 302
SARASOTA FL
34237-6056
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-0601
  • Fax: 352-332-9778
Mailing address:
  • Phone: 941-952-9411
  • Fax: 941-952-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1408096
License Number StateFL

VIII. Authorized Official

Name: MORRIS H. MILLER
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 941-952-9411