=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184337073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYTONA FL OPERATING COMPANY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2023
-----------------------------------------------------
Last Update Date | 10/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 S SEGRAVE ST
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-239-7520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23645 MERCANTILE RD STE J
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOSHUA STURM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-205-8235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------