Provider Demographics
NPI:1518941582
Name:BRANDYWINE CONVALESCENT CENTER INC
Entity Type:Organization
Organization Name:BRANDYWINE CONVALESCENT CENTER INC
Other - Org Name:BRANDYWYNE HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHARPLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-874-6007
Mailing Address - Street 1:1801 LAKE MARIAM DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-0927
Mailing Address - Country:US
Mailing Address - Phone:863-293-1989
Mailing Address - Fax:863-299-6427
Practice Address - Street 1:1801 LAKE MARIAM DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-0927
Practice Address - Country:US
Practice Address - Phone:863-293-1989
Practice Address - Fax:863-299-6427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF10600961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025139900Medicaid
FL105428Medicare Oscar/Certification