Provider Demographics
NPI:1952364572
Name:PLYMOUTH HARBOR, INC.
Entity Type:Organization
Organization Name:PLYMOUTH HARBOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIATSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-365-2600
Mailing Address - Street 1:700 JOHN RINGLING BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-1542
Mailing Address - Country:US
Mailing Address - Phone:941-365-2600
Mailing Address - Fax:941-361-7163
Practice Address - Street 1:700 JOHN RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-1542
Practice Address - Country:US
Practice Address - Phone:941-365-2600
Practice Address - Fax:941-361-7163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1449096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105817Medicare ID - Type Unspecified