Provider Demographics
NPI:1811042286
Name:PALMS OF LAUDERDALE LAKES THE LLC
Entity Type:Organization
Organization Name:PALMS OF LAUDERDALE LAKES THE LLC
Other - Org Name:THE PALMS REHABILITATION AND NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TZVI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGOMILSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-401-7901
Mailing Address - Street 1:1835 NE MIAMI GARDENS DR
Mailing Address - Street 2:#368
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3370 NW 47TH TER
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-6701
Practice Address - Country:US
Practice Address - Phone:954-733-0655
Practice Address - Fax:954-733-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1098096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032153200Medicaid
FL105336Medicare Oscar/Certification