Provider Demographics
NPI:1376684951
Name:POLK COUNTY, A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA
Entity Type:Organization
Organization Name:POLK COUNTY, A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA
Other - Org Name:POLK COUNTY BOARD OF COUNTY COMMISSIONERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER III
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-519-7579
Mailing Address - Street 1:2120 MARSHALL EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6731
Mailing Address - Country:US
Mailing Address - Phone:863-519-7579
Mailing Address - Fax:863-519-4783
Practice Address - Street 1:2120 MARSHALL EDWARDS DR
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6731
Practice Address - Country:US
Practice Address - Phone:863-519-7579
Practice Address - Fax:863-519-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14790951314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020253300Medicaid
FL020253300Medicaid