Healthcare Provider Details

I. General information

NPI: 1053309344
Provider Name (Legal Business Name): SENIOR CARE GOLFCREST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N 17TH AVE
HOLLYWOOD FL
33020-4606
US

IV. Provider business mailing address

600 N 17TH AVE
HOLLYWOOD FL
33020-4606
US

V. Phone/Fax

Practice location:
  • Phone: 954-927-2531
  • Fax: 954-927-0425
Mailing address:
  • Phone: 954-927-2531
  • Fax: 954-927-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF11760963
License Number StateFL

VIII. Authorized Official

Name: RAYMOND L TYLER JR.
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential:
Phone: 615-771-7575