Healthcare Provider Details

I. General information

NPI: 1548995863
Provider Name (Legal Business Name): GULFPORT NURSING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 PASADENA AVE S
SOUTH PASADENA FL
33707-3716
US

IV. Provider business mailing address

1430 PASADENA AVE S
SOUTH PASADENA FL
33707-3716
US

V. Phone/Fax

Practice location:
  • Phone: 727-344-8525
  • Fax: 855-887-9751
Mailing address:
  • Phone: 727-344-8525
  • Fax: 855-887-9751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MATHEW VARGHESE
Title or Position: MEMBER
Credential:
Phone: 917-817-3530