Provider Demographics
NPI:1770998072
Name:PROFESSIONAL CARE FACILITY ALF
Entity type:Organization
Organization Name:PROFESSIONAL CARE FACILITY ALF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-682-2155
Mailing Address - Street 1:5515 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-2928
Mailing Address - Country:US
Mailing Address - Phone:954-682-2155
Mailing Address - Fax:
Practice Address - Street 1:5515 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33068-2928
Practice Address - Country:US
Practice Address - Phone:954-682-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12012261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45048Medicare PIN
FL9523358316Medicare NSC