Provider Demographics
NPI:1952749053
Name:VAN-LEIGH OF VERO BEACH, LLC
Entity Type:Organization
Organization Name:VAN-LEIGH OF VERO BEACH, LLC
Other - Org Name:GREEN GABLES ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VAN BENSCHOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-794-1277
Mailing Address - Street 1:615 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1859
Mailing Address - Country:US
Mailing Address - Phone:772-794-1277
Mailing Address - Fax:772-794-2488
Practice Address - Street 1:1934 22ND AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3084
Practice Address - Country:US
Practice Address - Phone:772-794-1277
Practice Address - Fax:772-794-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9844310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684624600Medicare PIN