Provider Demographics
NPI:1457433864
Name:THE HEALTH CENTER OF COCONUT CREEK, INC.
Entity Type:Organization
Organization Name:THE HEALTH CENTER OF COCONUT CREEK, INC.
Other - Org Name:THE HEALTH CENTER OF COCONUT CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:954-968-8333
Mailing Address - Street 1:4125 W. SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073
Mailing Address - Country:US
Mailing Address - Phone:954-968-8333
Mailing Address - Fax:954-968-6898
Practice Address - Street 1:4125 W. SAMPLE RD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073
Practice Address - Country:US
Practice Address - Phone:954-968-8333
Practice Address - Fax:954-968-6898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
FLSNF130470979314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022658100Medicaid
L9COtherBLUE CROSS BLUE SHIELD
FL02265100Medicaid
FL022658100Medicaid