Healthcare Provider Details

I. General information

NPI: 1790772127
Provider Name (Legal Business Name): JOHN KNOX VILLAGE OF FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 LAKESIDE CIR
POMPANO BEACH FL
33060-7748
US

IV. Provider business mailing address

830 LAKESIDE CIR
POMPANO BEACH FL
33060-7748
US

V. Phone/Fax

Practice location:
  • Phone: 954-783-4000
  • Fax:
Mailing address:
  • Phone: 954-783-4090
  • Fax: 954-783-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1258096
License Number StateFL

VIII. Authorized Official

Name: DOUGLAS FOLSOM
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 954-783-4096