=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659416949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE GLADES MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 AVENUE J SW -MAIL NOT DELIVERED TO THIS RURAL ADDRESS
-----------------------------------------------------
City | MOORE HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33471-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-946-1000
-----------------------------------------------------
Fax | 863-946-1110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1332 51 AVE J
-----------------------------------------------------
City | MOORE HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33471-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-946-1000
-----------------------------------------------------
Fax | 863-946-1110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN DONALD GEAKE JR.
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 863-946-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS7165
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------