Provider Demographics
NPI:1669466173
Name:PENSACOLA SNF LLC
Entity Type:Organization
Organization Name:PENSACOLA SNF LLC
Other - Org Name:SOUTHERN OAKS REHAB & NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:A/R
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAVETZ
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING MANAGER
Authorized Official - Phone:732-942-1344
Mailing Address - Street 1:600 W. GREGORY ST.
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502
Mailing Address - Country:US
Mailing Address - Phone:850-437-3131
Mailing Address - Fax:
Practice Address - Street 1:600 W GREGORY ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4744
Practice Address - Country:US
Practice Address - Phone:850-437-3131
Practice Address - Fax:850-437-3733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1566096314000000X
FL14993314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026063100Medicaid
FL106051Medicare Oscar/Certification