Provider Demographics
NPI:1881681724
Name:SHADY REST CARE PAVILION, INC.
Entity type:Organization
Organization Name:SHADY REST CARE PAVILION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WESTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-8402
Mailing Address - Street 1:2310 N AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1426
Mailing Address - Country:US
Mailing Address - Phone:239-931-8401
Mailing Address - Fax:239-931-8453
Practice Address - Street 1:2310 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1426
Practice Address - Country:US
Practice Address - Phone:239-931-8401
Practice Address - Fax:239-931-8453
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHADY REST CARE PAVILION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-05
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1497096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021390000Medicaid
FL021390000Medicaid