Basic Information
| Provider Information | |||||||||
| NPI: | 1366848087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETRANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15164 NW 150TH AVE | ||||||||
| Address2: | APT.3057 | ||||||||
| City: | ALACHUA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326155540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865185290 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525486000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | NATASHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CERTIFIED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 3865185290 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 229833 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 26492528 | 05 | FL | MEDICAID |