MEDICARE: NORTHPORT HEALTH SERVICES OF FLORIDA, LLC

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
1	314000000X	Skilled Nursing Facility	SNF11210961	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1320620004	OTHER	DME SUPPLIER #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205881646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHPORT HEALTH SERVICES OF FLORIDA, LLC

Provider Business Mailing Address
First Line	:	1055 3RD ST
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 3RD ST
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4101
Country	:	US
Telephone Number	:	386-252-3686
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	PHILLIP CODY LONG
Credential	:
Telephone Number	:	205-391-3600

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	10/27/2020

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