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NPI Code Detail

MEDICARE: JACARANDA MANOR

MEDICARE: JACARANDA MANOR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing FacilitySNF1252096FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1SNF1252096OTHERFLLICENSE NUMBER

General Provider Information

NPI Number : 1205834413
Entity Type Code : Organization
Provider Name (Legal Business Name) : JACARANDA MANOR
Provider Business Mailing Address
First Line : 4250 66TH ST N
Second Line :
City : KENNETH CITY
State : FL
Zip : 33709-4918
Country : US
Telephone Number : 727-546-2405
Fax Number : 727-541-5154
Provider Business Practice Location Address
First Line : 4250 66TH ST N
Second Line :
City : KENNETH CITY
State : FL
Zip : 33709-4918
Country : US
Telephone Number : 727-546-2405
Fax Number : 727-541-5154
Authorized Official
Title or Position : ADMINISTRATOR
Name : MS. TERRI M WALKER
Credential : NHA
Telephone Number : 727-546-2405
Provider Enumeration Date : 07/12/2005
Last Update Date : 08/22/2020

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Directions to “JACARANDA MANOR ” Practice Location

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