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General NPI Number Information
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NPI Number | 1124775242
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Entity Type | Organization
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Legal Business Name | 2595 HARBOR BLVD LLC
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Dates
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Enumeration Date | 03/08/2022
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Last Update Date | 11/15/2022
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Provider Practice Location Address
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Address Line | 2595 HARBOR BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-6732
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Country | US
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Telephone | 941-769-9100
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Fax |
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Provider Business Mailing Address
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Address Line | 5307 E MOCKINGBIRD LN STE 575
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City | DALLAS
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State | TX
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Zip | 75206-5109
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Country | US
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Telephone | 469-619-5372
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JOSH ROSEN
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Credential |
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Telephone | 469-619-5372
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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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