Healthcare Provider Details

I. General information

NPI: 1366939647
Provider Name (Legal Business Name): COOPER CREEK FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2018
Last Update Date: 04/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5381 DESOTO ROAD
SARASOTA FL
34235
US

IV. Provider business mailing address

400 RELLA BLVD STE 200
MONTEBELLO NY
10901-4239
US

V. Phone/Fax

Practice location:
  • Phone: 941-355-6111
  • Fax:
Mailing address:
  • Phone: 845-490-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL BLEICH
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 845-641-8314