Healthcare Provider Details

I. General information

NPI: 1053429266
Provider Name (Legal Business Name): WILLISTON REHABILITATION AND NURSING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 08/20/2013
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

1835 NE MIAMI GARDENS DR #368
NORTH MIAMI BEACH FL
33179-5035
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 TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TZVI BOGOMILSKY
Title or Position: MEMBER
Credential:
Phone: 305-401-7901