Provider Demographics
NPI:1649399577
Name:ESC NEW PORT RICHEY, LLC
Entity Type:Organization
Organization Name:ESC NEW PORT RICHEY, LLC
Other - Org Name:EMERITUS AT FORT MYERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MEDICAID SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-298-2909
Mailing Address - Street 1:3131 ELLIOTT AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1044
Mailing Address - Country:US
Mailing Address - Phone:206-298-2909
Mailing Address - Fax:206-301-4500
Practice Address - Street 1:1896 PARK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3738
Practice Address - Country:US
Practice Address - Phone:239-939-5421
Practice Address - Fax:239-939-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 5096310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686854100Medicaid