Healthcare Provider Details

I. General information

NPI: 1912322801
Provider Name (Legal Business Name): GENESIS ALF OF TAMPA BAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 VILLAGE PL
BRANDON FL
33511-6240
US

IV. Provider business mailing address

714 VILLAGE PL
BRANDON FL
33511-6240
US

V. Phone/Fax

Practice location:
  • Phone: 813-638-5803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MISS GLADYS KANODEREKA
Title or Position: SECRETARY
Credential:
Phone: 813-638-5803