Provider Demographics
NPI:1700021599
Name:PENNEY RETIREMENT COMMUNITY
Entity Type:Organization
Organization Name:PENNEY RETIREMENT COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN VOLUNTEER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WHITNEY
Authorized Official - Last Name:JEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-284-4078
Mailing Address - Street 1:3495 HOFFMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PENNEY FARMS
Mailing Address - State:FL
Mailing Address - Zip Code:32079
Mailing Address - Country:US
Mailing Address - Phone:904-284-8579
Mailing Address - Fax:
Practice Address - Street 1:2 PAVILION PLACE
Practice Address - Street 2:
Practice Address - City:PENNEY FARMS
Practice Address - State:FL
Practice Address - Zip Code:32079
Practice Address - Country:US
Practice Address - Phone:904-284-8579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLL598313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicare UPIN