Provider Demographics
NPI:1114920584
Name:SOUTH BROWARD HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SOUTH BROWARD HOSPITAL DISTRICT
Other - Org Name:MEMORIAL MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEMYRE
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:954-276-6201
Mailing Address - Street 1:777 S DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1353
Mailing Address - Country:US
Mailing Address - Phone:954-431-1100
Mailing Address - Fax:954-443-4798
Practice Address - Street 1:777 S DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1353
Practice Address - Country:US
Practice Address - Phone:954-431-1100
Practice Address - Fax:954-443-4798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1342096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020100600Medicaid
FL020100600Medicaid
FL105668Medicare ID - Type UnspecifiedPROVIDER ID NUMBER