Healthcare Provider Details

I. General information

NPI: 1588054183
Provider Name (Legal Business Name): BVM CORAL LANDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5454
US

IV. Provider business mailing address

2820 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5454
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-2273
  • Fax:
Mailing address:
  • Phone: 904-794-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: SANDRA GUION
Title or Position: DIRECTOR OF TREASURY MANAGEMENT
Credential:
Phone: 317-806-6775