Provider Demographics
NPI:1477731529
Name:AVON PARK ROYAL HOLDINGS LLC
Entity Type:Organization
Organization Name:AVON PARK ROYAL HOLDINGS LLC
Other - Org Name:ROYAL CARE OF AVON PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-453-6674
Mailing Address - Street 1:1213 W STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-8091
Mailing Address - Country:US
Mailing Address - Phone:863-453-6674
Mailing Address - Fax:863-453-9473
Practice Address - Street 1:1213 W STRATFORD RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8091
Practice Address - Country:US
Practice Address - Phone:863-453-6674
Practice Address - Fax:863-453-9473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF12290951314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105812Medicare Oscar/Certification
FL032421300Medicaid