Provider Demographics
NPI:1366848087
Name:DEPARTMENT OF VETRANS AFFAIRS
Entity Type:Organization
Organization Name:DEPARTMENT OF VETRANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-518-5290
Mailing Address - Street 1:15164 NW 150TH AVE
Mailing Address - Street 2:APT.3057
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-5540
Mailing Address - Country:US
Mailing Address - Phone:386-518-5290
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-548-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL229833314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26492528Medicaid