Provider Demographics
NPI:1790772127
Name:JOHN KNOX VILLAGE OF FLORIDA, INC.
Entity Type:Organization
Organization Name:JOHN KNOX VILLAGE OF FLORIDA, INC.
Other - Org Name:JOHN KNOX VILLAGE HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FOLSOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-783-4096
Mailing Address - Street 1:830 LAKESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-7748
Mailing Address - Country:US
Mailing Address - Phone:954-783-4090
Mailing Address - Fax:954-783-4043
Practice Address - Street 1:830 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-7748
Practice Address - Country:US
Practice Address - Phone:954-783-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1258096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020376900Medicaid