Provider Demographics
NPI:1255311957
Name:HQM OF ORMOND BEACH, LLC
Entity Type:Organization
Organization Name:HQM OF ORMOND BEACH, LLC
Other - Org Name:ORMOND IN THE PINES REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-0664
Mailing Address - Street 1:103 CLYDE MORRIS BLVD
Mailing Address - Street 2:VOLUSIA COUNTY
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5982
Mailing Address - Country:US
Mailing Address - Phone:386-673-0450
Mailing Address - Fax:
Practice Address - Street 1:103 CLYDE MORRIS BLVD
Practice Address - Street 2:VOLUSIA COUNTY
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5982
Practice Address - Country:US
Practice Address - Phone:386-673-0450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1397096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-5458Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER