Healthcare Provider Details

I. General information

NPI: 1417556978
Provider Name (Legal Business Name): MH GENTRY PARK AL OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2020
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CENTER POINTE DR
ORLANDO FL
32825-6323
US

IV. Provider business mailing address

3201 CENTER POINTE DR
ORLANDO FL
32825-6323
US

V. Phone/Fax

Practice location:
  • Phone: 321-236-4406
  • Fax: 407-845-0886
Mailing address:
  • Phone: 321-236-4406
  • Fax: 407-845-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY JAMES VAUGHN
Title or Position: REIMBURSEMENT ANALYST
Credential:
Phone: 240-595-6025