=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134724487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR AGING AND REHABILITATION OF GULF COUNTY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2020
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 9TH ST
-----------------------------------------------------
City | PORT ST JOE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32456-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-229-8244
-----------------------------------------------------
Fax | 850-229-1042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 SE 2ND ST STE 2000
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33131-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-367-4597
-----------------------------------------------------
Fax | 954-367-4564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT ALAN BROCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-367-4597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------