Provider Demographics
NPI:1396906707
Name:POLK COUNTY BOARD OF COUNTY COMMISSIONERS
Entity type:Organization
Organization Name:POLK COUNTY BOARD OF COUNTY COMMISSIONERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL (SAM)
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-534-6049
Mailing Address - Street 1:2135 MARSHALL EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6757
Mailing Address - Country:US
Mailing Address - Phone:863-534-5659
Mailing Address - Fax:863-534-5678
Practice Address - Street 1:615 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3813
Practice Address - Country:US
Practice Address - Phone:863-534-0393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)