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General NPI Number Information
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NPI Number | 1730621590
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Entity Type | Organization
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Legal Business Name | NONE AT THIS TIME
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Dates
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Enumeration Date | 11/10/2016
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Last Update Date | 11/10/2016
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Provider Practice Location Address
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Address Line | 725 CRESTWOOD DR
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City | WINTER HAVEN
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State | FL
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Zip | 33881-2919
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Country | US
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Telephone | 863-618-9182
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Fax |
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Provider Business Mailing Address
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Address Line | 725 CRESTWOOD DR
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City | WINTER HAVEN
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State | FL
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Zip | 33881-2919
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Country | US
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Telephone | 863-618-9182
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Fax |
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Authorized Official
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Title or Position | ASSITANT DIRECTOR OF NURSING
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Name | MISS WILENE CHARLEMONT PIERRE
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Credential | R.N.
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Telephone | 863-618-9182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | RN9313465
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License Number State | FL
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