MEDICARE: GRACE MANOR ALF LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	13186	FL

General Provider Information

NPI Number	:	1306330774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE MANOR ALF LLC

Provider Business Mailing Address
First Line	:	5916 45TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33709-5105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5916 45TH AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33709-5105
Country	:	US
Telephone Number	:	727-666-5060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARYANN PANTONIAL
Credential	:
Telephone Number	:	727-666-5060

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	06/19/2018

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