=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679944268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLARIS HEALTHCARE MERRITT ISLAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2015
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 CROCKETT BLVD
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-5034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-454-4035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3310
-----------------------------------------------------
City | WINDERMERE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34786-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | STACEY WILKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-454-4035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------