=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023090453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2005
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 N TAMIAMI TRL
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34236-2432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-953-6949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1303 N TAMIAMI TRL
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34236-2432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-953-6949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DEBRA S. SANDBERG
-----------------------------------------------------
Credential | NHA NURSING HOME ADM
-----------------------------------------------------
Telephone | 941-953-6949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF16370968
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------