Provider Demographics
NPI:1063833788
Name:SRI AT HEALTH PARK, LLC
Entity Type:Organization
Organization Name:SRI AT HEALTH PARK, LLC
Other - Org Name:SUPERIOR RESIDENCES AT HEALTH PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-686-3831
Mailing Address - Street 1:9461 HEALTHPARK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3614
Mailing Address - Country:US
Mailing Address - Phone:239-437-5511
Mailing Address - Fax:
Practice Address - Street 1:9461 HEALTHPARK CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3614
Practice Address - Country:US
Practice Address - Phone:239-437-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR RESIDENCES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9346310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9346OtherAHCA