Provider Demographics
NPI:1487641189
Name:SOVEREIGN HEALTHCARE OF WEST PALM BEACH, LLC
Entity Type:Organization
Organization Name:SOVEREIGN HEALTHCARE OF WEST PALM BEACH, LLC
Other - Org Name:BOULEVARD REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:2839 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7934
Practice Address - Country:US
Practice Address - Phone:561-732-2462
Practice Address - Fax:561-369-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1058096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026361300Medicaid
V548P-1063OtherVA
FL026361300Medicaid
V548P-1063OtherVA