Provider Demographics
NPI:1316939804
Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-518-3202
Mailing Address - Street 1:6919 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-2909
Mailing Address - Country:US
Mailing Address - Phone:813-558-5000
Mailing Address - Fax:813-558-5021
Practice Address - Street 1:6919 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-2909
Practice Address - Country:US
Practice Address - Phone:727-518-3202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106006Medicare ID - Type Unspecified