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General NPI Number Information
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NPI Number | 1083201891
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Entity Type | Organization
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Legal Business Name | A BANYAN RESIDENCE AT WILDWOOD, LLC
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Dates
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Enumeration Date | 12/28/2020
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Last Update Date | 12/28/2020
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Provider Practice Location Address
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Address Line | 12427 COUNTY ROAD 101
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City | OXFORD
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State | FL
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Zip | 34484-2941
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Country | US
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Telephone | 954-854-8895
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Fax | 941-412-4749
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Provider Business Mailing Address
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Address Line | 2515 SHERMAN OAK DR
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City | NORTH PORT
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State | FL
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Zip | 34289-2390
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Country | US
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Telephone | 941-249-0456
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Fax | 941-412-4749
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | GREG ANDERSON
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Credential |
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Telephone | 954-536-4066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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