Provider Demographics
NPI:1821044488
Name:MERRITT ISLAND HEALTH CARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:MERRITT ISLAND HEALTH CARE ASSOCIATES LLC
Other - Org Name:ISLAND HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GANARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-453-0202
Mailing Address - Street 1:125 ALMA BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4345
Mailing Address - Country:US
Mailing Address - Phone:321-453-0202
Mailing Address - Fax:321-453-0323
Practice Address - Street 1:125 ALMA BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4345
Practice Address - Country:US
Practice Address - Phone:321-453-0202
Practice Address - Fax:321-453-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1349096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025235200Medicaid
FL025235200Medicaid