Healthcare Provider Details

I. General information

NPI: 1629060272
Provider Name (Legal Business Name): FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21281 GRAYTON TER
PORT CHARLOTTE FL
33954-3109
US

IV. Provider business mailing address

21281 GRAYTON TER
PORT CHARLOTTE FL
33954-3109
US

V. Phone/Fax

Practice location:
  • Phone: 941-613-0919
  • Fax: 941-613-0935
Mailing address:
  • Phone: 941-613-0919
  • Fax: 941-613-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. WILLIAM G PUCKETT
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 727-518-3202