Healthcare Provider Details

I. General information

NPI: 1518941582
Provider Name (Legal Business Name): BRANDYWINE CONVALESCENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 LAKE MARIAM DR
WINTER HAVEN FL
33884-0927
US

IV. Provider business mailing address

1801 LAKE MARIAM DR
WINTER HAVEN FL
33884-0927
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-1989
  • Fax: 863-299-6427
Mailing address:
  • Phone: 863-293-1989
  • Fax: 863-299-6427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF10600961
License Number StateFL

VIII. Authorized Official

Name: VICTORIA LYNN SHARPLESS
Title or Position: DIRECTOR OF ACCOUNTING
Credential:
Phone: 352-874-6007