Healthcare Provider Details

I. General information

NPI: 1366433385
Provider Name (Legal Business Name): ST PETERSBURG NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 66TH ST N
KENNETH CITY FL
33709-4918
US

IV. Provider business mailing address

4250 66TH ST N
KENNETH CITY FL
33709-4918
US

V. Phone/Fax

Practice location:
  • Phone: 727-546-2405
  • Fax:
Mailing address:
  • Phone: 727-546-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1252096
License Number StateFL

VIII. Authorized Official

Name: MICHELLE BURDETTE
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 423-308-1845