Provider Demographics
NPI:1851360242
Name:WOODLANDS EXTENDED CARE INC
Entity Type:Organization
Organization Name:WOODLANDS EXTENDED CARE INC
Other - Org Name:WOODLANDS TERRACE EXTENDED CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-255-1054
Mailing Address - Street 1:120 W CHIPOLA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7704
Mailing Address - Country:US
Mailing Address - Phone:386-738-3433
Mailing Address - Fax:386-740-8308
Practice Address - Street 1:120 W CHIPOLA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7704
Practice Address - Country:US
Practice Address - Phone:386-738-3433
Practice Address - Fax:386-740-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16490961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021263600Medicaid
FL105930Medicare ID - Type UnspecifiedPROVIDER NUMBER