Healthcare Provider Details

I. General information

NPI: 1821011958
Provider Name (Legal Business Name): 1501 SE 24TH ROAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SE 24TH RD
OCALA FL
34471-6005
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 352-629-8900
  • Fax: 352-351-4806
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 13780951
License Number StateFL

VIII. Authorized Official

Name: WILLIAM A MATHIES
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355