Healthcare Provider Details

I. General information

NPI: 1700021599
Provider Name (Legal Business Name): PENNEY RETIREMENT COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PAVILION PLACE
PENNEY FARMS FL
32079
US

IV. Provider business mailing address

3495 HOFFMAN AVENUE
PENNEY FARMS FL
32079
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-8579
  • Fax:
Mailing address:
  • Phone: 904-284-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberLL598
License Number StateFL

VIII. Authorized Official

Name: DR. PAUL WHITNEY JEWETT
Title or Position: PHYSICIAN VOLUNTEER
Credential: MD
Phone: 904-284-4078