=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770782583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILDWOOD SNF LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 S OLD WIRE RD
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34785-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-748-3322
-----------------------------------------------------
Fax | 352-748-7609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1835 NE MIAMI GARDENS DR #368
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-5035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MR. TZVI BOGOMILSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-401-7901
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1588096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------