Provider Demographics
NPI:1083201891
Name:A BANYAN RESIDENCE AT WILDWOOD, LLC
Entity Type:Organization
Organization Name:A BANYAN RESIDENCE AT WILDWOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-536-4066
Mailing Address - Street 1:2515 SHERMAN OAK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34289-2390
Mailing Address - Country:US
Mailing Address - Phone:941-249-0456
Mailing Address - Fax:941-412-4749
Practice Address - Street 1:12427 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-2941
Practice Address - Country:US
Practice Address - Phone:954-854-8895
Practice Address - Fax:941-412-4749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A BANYAN RESIDENCE ASSISTED LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility