Provider Demographics
NPI:1053429266
Name:WILLISTON REHABILITATION AND NURSING CENTER LLC
Entity type:Organization
Organization Name:WILLISTON REHABILITATION AND NURSING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TZVI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGOMILSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-401-7901
Mailing Address - Street 1:1835 NE MIAMI GARDENS DR
Mailing Address - Street 2:#368
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2006
Practice Address - Country:US
Practice Address - Phone:352-528-3561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031758600Medicaid
FL031758600Medicaid