Healthcare Provider Details

I. General information

NPI: 1710381736
Provider Name (Legal Business Name): SWAN S.P. ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 17TH ST
RIVIERA BEACH FL
33404-6121
US

IV. Provider business mailing address

45 W 17TH ST
RIVIERA BEACH FL
33404-6121
US

V. Phone/Fax

Practice location:
  • Phone: 561-863-7481
  • Fax: 561-863-7396
Mailing address:
  • Phone: 561-863-7481
  • Fax: 561-863-7396

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 Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: SANDRA M CAMERON
Title or Position: ADMINISTRATOR
Credential:
Phone: 561-863-7481