Provider Demographics
NPI:1548995863
Name:GULFPORT NURSING CENTER LLC
Entity type:Organization
Organization Name:GULFPORT NURSING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-817-3530
Mailing Address - Street 1:1430 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3716
Mailing Address - Country:US
Mailing Address - Phone:727-344-8525
Mailing Address - Fax:855-887-9751
Practice Address - Street 1:1430 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-3716
Practice Address - Country:US
Practice Address - Phone:727-344-8525
Practice Address - Fax:855-887-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14320962OtherLICENSE