Provider Demographics
NPI:1538400072
Name:VARNUM, RUBY LEE
Entity type:Individual
Prefix:MRS
First Name:RUBY
Middle Name:LEE
Last Name:VARNUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12167 NW FREEMAN ROAD
Mailing Address - Street 2:VARNUM'S REST HOME
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321
Mailing Address - Country:US
Mailing Address - Phone:850-643-5155
Mailing Address - Fax:850-643-3721
Practice Address - Street 1:12167 NW FREEMAN RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321
Practice Address - Country:US
Practice Address - Phone:850-643-5155
Practice Address - Fax:850-643-3721
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6026310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140029100Medicaid
FL679025900Medicaid