Provider Demographics
NPI:1538192208
Name:PHOENIX HEALTHCARE PROPERTIES OF MANDARIN, LLC
Entity type:Organization
Organization Name:PHOENIX HEALTHCARE PROPERTIES OF MANDARIN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DION
Authorized Official - Middle Name:R
Authorized Official - Last Name:SENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-759-4046
Mailing Address - Street 1:199 NE 89TH STREET
Mailing Address - Street 2:
Mailing Address - City:EL PORTAL
Mailing Address - State:FL
Mailing Address - Zip Code:33138-3010
Mailing Address - Country:US
Mailing Address - Phone:305-759-4046
Mailing Address - Fax:305-759-4056
Practice Address - Street 1:10680 SAINT AUGUSTINE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1000
Practice Address - Country:US
Practice Address - Phone:904-268-4953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF13060961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031237100Medicaid
FLL69OtherBLUE CROSS INSURANCE
FLL69OtherBLUE CROSS INSURANCE