Provider Demographics
NPI:1275969628
Name:DELAND GERIATRIC CARE, INC.
Entity Type:Organization
Organization Name:DELAND GERIATRIC CARE, INC.
Other - Org Name:THE GOOD SHEPARDS-WEST OF DELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, RESIDENT CARE SERVICES/CO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:LORENZANA
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:386-738-9986
Mailing Address - Street 1:208 BLUE CRYSTAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720
Mailing Address - Country:US
Mailing Address - Phone:386-679-3375
Mailing Address - Fax:386-738-9986
Practice Address - Street 1:208 BLUE CRYSTAL DRIVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-679-3375
Practice Address - Fax:386-738-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8722310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility