Provider Demographics
NPI:1093786667
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:A.G. HOLLEY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL ADMIN. SERVICES COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-540-3377
Mailing Address - Street 1:1199 W LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1514
Mailing Address - Country:US
Mailing Address - Phone:561-582-5666
Mailing Address - Fax:561-540-3788
Practice Address - Street 1:1199 W LANTANA RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1514
Practice Address - Country:US
Practice Address - Phone:561-582-5666
Practice Address - Fax:561-540-3788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3979281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102000Medicare ID - Type UnspecifiedMCR PROVIDER