=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851360242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODLANDS EXTENDED CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2006
-----------------------------------------------------
Last Update Date | 04/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W CHIPOLA AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-3433
-----------------------------------------------------
Fax | 386-740-8308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W CHIPOLA AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-3433
-----------------------------------------------------
Fax | 386-740-8308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOKKEEPER
-----------------------------------------------------
Name | MS. DONNA J MARSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-255-1054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 16490961
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------