Heritage Waterside

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

HERITAGE WATERSIDE

Practice address

3704 Cardinal Blvd
Daytona Beach Shores, FL 32118-7301

Phone

(386) 256-2015

NPI assigned

May 11, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark Nagrani, MD

Title

Owner

Phone

(386) 256-2015

Specialties & licenses 1

Addresses

Other identifiers 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620691200000",
    "number": "1114501574",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3704 CARDINAL BLVD",
            "city": "DAYTONA BEACH SHORES",
            "state": "FL",
            "postal_code": "321187301",
            "telephone_number": "386-256-2015"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3704 CARDINAL BLVD",
            "city": "DAYTONA BEACH SHORES",
            "state": "FL",
            "postal_code": "321187301",
            "telephone_number": "386-256-2015"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HERITAGE WATERSIDE",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-11",
        "last_updated": "2021-05-11",
        "certification_date": "2021-05-11",
        "status": "A",
        "authorized_official_last_name": "NAGRANI",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "386-256-2015",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "109599800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Daytona Beach Shores, FL
• Providers in Daytona Beach Shores, FL by specialty
• Assisted Living Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.