Provider Demographics
NPI:1376741124
Name:INDIGO PALMS
Entity Type:Organization
Organization Name:INDIGO PALMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JAMESON MARSH
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:I
Authorized Official - Credentials:CALA
Authorized Official - Phone:386-238-3333
Mailing Address - Street 1:570 NATIONAL HEALTH CARE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1494
Mailing Address - Country:US
Mailing Address - Phone:386-238-3333
Mailing Address - Fax:386-238-3414
Practice Address - Street 1:570 NATIONAL HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1494
Practice Address - Country:US
Practice Address - Phone:386-238-3333
Practice Address - Fax:386-238-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9261310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL9261OtherFLORIDA LICENSE NUMBER