Healthcare Provider Details

I. General information

NPI: 1932393097
Provider Name (Legal Business Name): WOODGATE PLACE ALF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 HAWTHORNE DR
CLEARWATER FL
33763-1511
US

IV. Provider business mailing address

2314 HAWTHORNE DR
CLEARWATER FL
33763-1511
US

V. Phone/Fax

Practice location:
  • Phone: 727-797-9678
  • Fax: 727-796-5282
Mailing address:
  • Phone: 727-797-9678
  • Fax: 727-796-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateFL

VIII. Authorized Official

Name: MISS VELMA WAJE TIZON
Title or Position: OWNER ADMINISTRATOR
Credential:
Phone: 727-797-9678