Provider Demographics
NPI:1326381609
Name:GV-ORMOND, LLC
Entity Type:Organization
Organization Name:GV-ORMOND, LLC
Other - Org Name:GRAND VILLA OF ORMOND BEACH
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 1:535 N NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4405
Practice Address - Country:US
Practice Address - Phone:386-673-5000
Practice Address - Fax:386-673-0168
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
FLAL7460310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000592000Medicaid