Healthcare Provider Details

I. General information

NPI: 1801810551
Provider Name (Legal Business Name): 1980 SUNSET POINT ROAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 SUNSET POINT RD
CLEARWATER FL
33765-1132
US

IV. Provider business mailing address

101 E STATE ST COMPLIANCE DEPARTMENT
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 727-443-1588
  • Fax: 727-442-5916
Mailing address:
  • Phone: 505-468-4742
  • Fax: 505-468-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 15370961
License Number StateFL

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742