Provider Demographics
NPI:1033498746
Name:HOLLYWOOD BEACH RETIREMENT HOME
Entity Type:Organization
Organization Name:HOLLYWOOD BEACH RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANETI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-923-1726
Mailing Address - Street 1:1722 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5537
Mailing Address - Country:US
Mailing Address - Phone:954-923-1726
Mailing Address - Fax:954-923-8535
Practice Address - Street 1:1722 MADISON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5537
Practice Address - Country:US
Practice Address - Phone:954-923-1726
Practice Address - Fax:954-923-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL50263104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140923900Medicaid