Healthcare Provider Details

I. General information

NPI: 1366936197
Provider Name (Legal Business Name): 5901 NW 79TH AVENUE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 NW 79TH AVE
TAMARAC FL
33321
US

IV. Provider business mailing address

5901 NW 79TH AVE
TAMARAC FL
33321-4639
US

V. Phone/Fax

Practice location:
  • Phone: 407-571-1550
  • Fax:
Mailing address:
  • Phone: 954-722-7001
  • Fax: 954-720-5419

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: MIRIAM C. PASTOR
Title or Position: MANAGER
Credential:
Phone: 813-769-6280