Healthcare Provider Details

I. General information

NPI: 1346627031
Provider Name (Legal Business Name): WILLISTON FACILITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 NW 1ST AVE
WILLISTON FL
32696-2006
US

IV. Provider business mailing address

4302 HOLLYWOOD BLVD #369
HOLLYWOOD FL
33021-6635
US

V. Phone/Fax

Practice location:
  • Phone: 352-528-3561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1381096
License Number StateFL

VIII. Authorized Official

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