Healthcare Provider Details

I. General information

NPI: 1366421836
Provider Name (Legal Business Name): HQM OF SURREY PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LEE AVE SE
LIVE OAK FL
32064-9504
US

IV. Provider business mailing address

110 LEE AVE SE
LIVE OAK FL
32064-9504
US

V. Phone/Fax

Practice location:
  • Phone: 386-364-5961
  • Fax:
Mailing address:
  • Phone: 386-364-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1540096
License Number StateFL

VIII. Authorized Official

Name: MR. PAUL WALCZAK
Title or Position: CEO
Credential:
Phone: 561-627-0664