Provider Demographics
NPI:1649462359
Name:VA MEDICAL CENTER
Entity type:Organization
Organization Name:VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MISS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-916-6755
Mailing Address - Street 1:16840 SE 52ND PL
Mailing Address - Street 2:
Mailing Address - City:OCKLAWAHA
Mailing Address - State:FL
Mailing Address - Zip Code:32179-2836
Mailing Address - Country:US
Mailing Address - Phone:386-916-6755
Mailing Address - Fax:
Practice Address - Street 1:1920 MASON AVE
Practice Address - Street 2:EMORY L BENNETT VA NURSING HOME
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5103
Practice Address - Country:US
Practice Address - Phone:386-274-3460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2047752314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility