Healthcare Provider Details

I. General information

NPI: 1285630582
Provider Name (Legal Business Name): SA-PG-GAINESVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 SW 62ND BLVD
GAINESVILLE FL
32607-2084
US

IV. Provider business mailing address

227 SW 62ND BLVD
GAINESVILLE FL
32607-2084
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-0601
  • Fax: 352-332-9778
Mailing address:
  • Phone: 352-331-0601
  • Fax: 352-332-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1408096
License Number StateFL

VIII. Authorized Official

Name: MR. ALEX PALEY
Title or Position: COO
Credential:
Phone: 914-390-4363