Provider Demographics
NPI:1720495120
Name:FMHR LLC
Entity Type:Organization
Organization Name:FMHR LLC
Other - Org Name:FOUNTAIN MANOR HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-895-4804
Mailing Address - Street 1:390 NE 135TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-3967
Mailing Address - Country:US
Mailing Address - Phone:305-895-4804
Mailing Address - Fax:305-892-7411
Practice Address - Street 1:390 NE 135TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-3967
Practice Address - Country:US
Practice Address - Phone:305-895-4804
Practice Address - Fax:305-892-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1163096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013244900Medicaid
FL105172Medicare Oscar/Certification