Provider Demographics
NPI:1477064095
Name:POTTER'S HOUSE AT CANNON POINT, INC
Entity Type:Organization
Organization Name:POTTER'S HOUSE AT CANNON POINT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-733-3366
Mailing Address - Street 1:5820 5830 NW 27TH CT
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2330
Mailing Address - Country:US
Mailing Address - Phone:954-733-3366
Mailing Address - Fax:954-733-2993
Practice Address - Street 1:5820 5830 NW 27TH CT
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-2330
Practice Address - Country:US
Practice Address - Phone:954-733-3366
Practice Address - Fax:954-733-2993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10434310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002314100Medicaid