Provider Demographics
NPI:1124002647
Name:PEACE RIVER HMA NURSING CENTER INC
Entity Type:Organization
Organization Name:PEACE RIVER HMA NURSING CENTER INC
Other - Org Name:PEACE RIVER NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP AND GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:239-598-3176
Mailing Address - Street 1:2370 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-624-5966
Mailing Address - Fax:941-766-5351
Practice Address - Street 1:2370 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-624-5966
Practice Address - Fax:941-766-5351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030902800Medicaid
FL030902800Medicaid