Healthcare Provider Details

I. General information

NPI: 1265849830
Provider Name (Legal Business Name): SKILLED NURSING CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 AARON ST
PORT CHARLOTTE FL
33952-5305
US

IV. Provider business mailing address

3434 HANCOCK BRIDGE PKWY STE 301
NORTH FORT MYERS FL
33903-7094
US

V. Phone/Fax

Practice location:
  • Phone: 855-670-7400
  • Fax: 855-674-7401
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID KOENINGER
Title or Position: CFO
Credential:
Phone: 855-674-7400