Provider Demographics
NPI:1669479192
Name:RIVER GARDEN HEBREW HOME FOR THE AGED
Entity Type:Organization
Organization Name:RIVER GARDEN HEBREW HOME FOR THE AGED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MPA, NHA
Authorized Official - Phone:904-260-1818
Mailing Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1402
Mailing Address - Country:US
Mailing Address - Phone:904-260-1818
Mailing Address - Fax:904-260-9733
Practice Address - Street 1:11401 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-260-1818
Practice Address - Fax:904-260-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHA299991334251E00000X
FLSNF1476096313M00000X, 314000000X, 332BN1400X, 332BP3500X
FLPH2050333600000X
FLPH13972333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251E00000XAgenciesHome Health
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020085900Medicaid
FL102186900Medicaid
FL102186900Medicaid
FL0588760001Medicare NSC