Provider Demographics
NPI:1760783872
Name:DEPAUL OF WEST ORLANDO
Entity Type:Organization
Organization Name:DEPAUL OF WEST ORLANDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / NURSE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRTLE
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:BENJAMIN-RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-292-0515
Mailing Address - Street 1:1201 PAUL ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-6938
Mailing Address - Country:US
Mailing Address - Phone:407-292-0515
Mailing Address - Fax:407-292-4818
Practice Address - Street 1:1201 PAUL ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-6938
Practice Address - Country:US
Practice Address - Phone:407-292-0515
Practice Address - Fax:407-292-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9119310400000X
FLRN 916612310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678900500OtherMEDICARE
FL140219600Medicaid