Provider Demographics
NPI:1679560262
Name:DEEP CREEK RNC, LLC
Entity Type:Organization
Organization Name:DEEP CREEK RNC, LLC
Other - Org Name:PORT CHARLOTTE REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER OF SBK CAPITAL LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-233-7048
Mailing Address - Street 1:25325 RAMPART BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33983-6404
Mailing Address - Country:US
Mailing Address - Phone:941-629-7466
Mailing Address - Fax:941-629-9053
Practice Address - Street 1:25325 RAMPART BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33983
Practice Address - Country:US
Practice Address - Phone:941-629-7466
Practice Address - Fax:941-629-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14260961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
V516P-6820OtherVA
FL0319325 00Medicaid
FL105524Medicare Oscar/Certification