Provider Demographics
NPI:1700882370
Name:HEALTHCARE PROPERTIES OF ST AUGUSTINE INC
Entity Type:Organization
Organization Name:HEALTHCARE PROPERTIES OF ST AUGUSTINE INC
Other - Org Name:PONCE DE LEON CARE CENTER OR THE PONCE THERAPY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KEELY
Authorized Official - Middle Name:MCLAREN
Authorized Official - Last Name:HIRSCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-297-1020
Mailing Address - Street 1:210 25TH AVE NORTH
Mailing Address - Street 2:SUITE 508
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203
Mailing Address - Country:US
Mailing Address - Phone:615-297-1020
Mailing Address - Fax:615-383-3083
Practice Address - Street 1:1999 OLD MOULTRIE RD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5164
Practice Address - Country:US
Practice Address - Phone:904-824-3311
Practice Address - Fax:904-825-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1450096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0538930001Medicare NSC
FL105468Medicare Oscar/Certification