Provider Demographics
NPI:1205179652
Name:GV MELBOURNE, INC.
Entity Type:Organization
Organization Name:GV MELBOURNE, INC.
Other - Org Name:GRAND VILLA OF MELBOURNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-3980
Mailing Address - Street 1:13770 58TH ST N
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3759
Mailing Address - Country:US
Mailing Address - Phone:727-726-3980
Mailing Address - Fax:727-726-5345
Practice Address - Street 1:964 S HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1909
Practice Address - Country:US
Practice Address - Phone:321-725-0300
Practice Address - Fax:321-725-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11991310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility