=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285068908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMSON VILLA OF ORANGE PARK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2013
-----------------------------------------------------
Last Update Date | 08/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2757 PEBBLERIDGE CT
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-6261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-375-2011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2757 PEBBLERIDGE COURT
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MR. SAMUEL CORBETT GRANGER II
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-755-8707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12338
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------