Provider Demographics
NPI:1659350114
Name:HQM OF SUTTON PLACE, LLC
Entity Type:Organization
Organization Name:HQM OF SUTTON PLACE, LLC
Other - Org Name:SUTTON PLACE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-0664
Mailing Address - Street 1:4405 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3414
Mailing Address - Country:US
Mailing Address - Phone:561-969-1400
Mailing Address - Fax:
Practice Address - Street 1:4405 LAKEWOOD RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3414
Practice Address - Country:US
Practice Address - Phone:561-969-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME QUALITY MANAGEMENT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-12
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1544096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025711700Medicaid
6068700001Medicare NSC
FL025711700Medicaid