Healthcare Provider Details

I. General information

NPI: 1609322312
Provider Name (Legal Business Name): GLENMOOR OPCO VENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 TOWERVIEW DRIVE
SAINT AUGUSTINE FL
32092-2789
US

IV. Provider business mailing address

230 TOWERVIEW DRIVE
SAINT AUGUSTINE FL
32092-2789
US

V. Phone/Fax

Practice location:
  • Phone: 515-875-4500
  • Fax: 515-875-4780
Mailing address:
  • Phone: 515-875-4500
  • Fax: 515-875-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: JUDI L BUXO
Title or Position: ASSISTANT CORPORATE SECRETARY
Credential:
Phone: 515-875-4500