Healthcare Provider Details

I. General information

NPI: 1770132755
Provider Name (Legal Business Name): HIBISCUS PALACE WELLINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 HYACINTH PL APT C
WELLINGTON FL
33414-2144
US

IV. Provider business mailing address

7181 VIA LEONARDO
LAKE WORTH FL
33467-5236
US

V. Phone/Fax

Practice location:
  • Phone: 561-333-4179
  • Fax: 561-909-1548
Mailing address:
  • Phone: 561-385-2532
  • Fax: 561-909-1548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: ANDREA WRIGHT MATTIS
Title or Position: ADMINISTRATOR
Credential: MSN, RN
Phone: 561-385-2532