Provider Demographics
NPI:1679560577
Name:WALTON COUNTY CONVALESCENT CENTER OPERATIONS, L.L.C.
Entity Type:Organization
Organization Name:WALTON COUNTY CONVALESCENT CENTER OPERATIONS, L.L.C.
Other - Org Name:CHAUTAUQUA REHABILITATION AND NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DRIES
Authorized Official - Suffix:
Authorized Official - Credentials:NH
Authorized Official - Phone:850-892-2176
Mailing Address - Street 1:785 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-4903
Mailing Address - Country:US
Mailing Address - Phone:850-892-2176
Mailing Address - Fax:850-892-0781
Practice Address - Street 1:785 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-4903
Practice Address - Country:US
Practice Address - Phone:850-892-2176
Practice Address - Fax:850-892-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105626Medicare ID - Type Unspecified