Provider Demographics
NPI:1578559902
Name:ST JOHNS REHABILITATION HOSPITAL AND NURSING CENTER INC
Entity Type:Organization
Organization Name:ST JOHNS REHABILITATION HOSPITAL AND NURSING CENTER INC
Other - Org Name:ST JOHNS NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:954-739-6233
Mailing Address - Street 1:3075 NW 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1107
Mailing Address - Country:US
Mailing Address - Phone:954-739-6233
Mailing Address - Fax:954-733-9579
Practice Address - Street 1:3075 NW 35TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1107
Practice Address - Country:US
Practice Address - Phone:954-739-6233
Practice Address - Fax:954-733-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL313M00000X
FLSNF1520096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020580000Medicaid
FL020580000Medicaid