Provider Demographics
NPI:1003288499
Name:BORT, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:BORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 WOODBURY PINES CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9086
Mailing Address - Country:US
Mailing Address - Phone:407-719-0496
Mailing Address - Fax:407-270-8300
Practice Address - Street 1:227 WOODBURY PINES CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9086
Practice Address - Country:US
Practice Address - Phone:407-719-0496
Practice Address - Fax:407-270-8300
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906728311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home