Provider Demographics
NPI:1912215583
Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:CLYDE E LASSEN STATE VETERANS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PAULISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-940-2193
Mailing Address - Street 1:4650 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0600
Mailing Address - Country:US
Mailing Address - Phone:904-940-2193
Mailing Address - Fax:904-940-0316
Practice Address - Street 1:4650 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0600
Practice Address - Country:US
Practice Address - Phone:904-940-2193
Practice Address - Fax:904-940-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH24880314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility