Provider Demographics
NPI:1518959667
Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-518-3202
Mailing Address - Street 1:4419 TRAM RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-2559
Mailing Address - Country:US
Mailing Address - Phone:850-747-5401
Mailing Address - Fax:850-747-5301
Practice Address - Street 1:4419 TRAM RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-2559
Practice Address - Country:US
Practice Address - Phone:850-747-5401
Practice Address - Fax:850-747-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106056Medicare ID - Type Unspecified