Provider Demographics
NPI:1760499404
Name:HOBE SOUND GERIATRIC VILLAGE, INC.
Entity Type:Organization
Organization Name:HOBE SOUND GERIATRIC VILLAGE, INC.
Other - Org Name:EDGEWATER MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-759-5966
Mailing Address - Street 1:11700 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-3903
Mailing Address - Country:US
Mailing Address - Phone:586-759-5966
Mailing Address - Fax:586-759-8006
Practice Address - Street 1:9555 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-2009
Practice Address - Country:US
Practice Address - Phone:772-546-5800
Practice Address - Fax:772-546-6567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13200961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105300Medicare ID - Type UnspecifiedPROVIDER NUMBER