Healthcare Provider Details

I. General information

NPI: 1689683443
Provider Name (Legal Business Name): MK OF WINTER GARDEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12751 W COLONIAL DR
WINTER GARDEN FL
34787-4113
US

IV. Provider business mailing address

12751 W COLONIAL DR
WINTER GARDEN FL
34787-4113
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-6636
  • Fax:
Mailing address:
  • Phone: 407-877-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1456096
License Number StateFL

VIII. Authorized Official

Name: MRS. TARRY HARBILAS
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-877-6636