Provider Demographics
NPI:1558467324
Name:DOS OF EDEN SPRINGS LLC
Entity Type:Organization
Organization Name:DOS OF EDEN SPRINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-868-1830
Mailing Address - Street 1:4679 CRAWFORDVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-4539
Mailing Address - Country:US
Mailing Address - Phone:850-926-7181
Mailing Address - Fax:850-926-3064
Practice Address - Street 1:4679 CRAWFORDVILLE HWY
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-4539
Practice Address - Country:US
Practice Address - Phone:850-926-7181
Practice Address - Fax:850-926-3064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1582096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025370700Medicaid
FL105282Medicare ID - Type UnspecifiedMEDICARE