Provider Demographics
NPI:1447459334
Name:SHP III HERON FORT MYERS, LLC
Entity type:Organization
Organization Name:SHP III HERON FORT MYERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-395-8635
Mailing Address - Street 1:2 RAVINIA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9731 COMMERCE CENTER CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1400
Practice Address - Country:US
Practice Address - Phone:239-334-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLICENSE PENDING310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility