Healthcare Provider Details

I. General information

NPI: 1346238631
Provider Name (Legal Business Name): SENIOR CARE SOUTHERN PINES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 CONGRESS ST
NEW PORT RICHEY FL
34653-3909
US

IV. Provider business mailing address

6140 CONGRESS ST
NEW PORT RICHEY FL
34653-3909
US

V. Phone/Fax

Practice location:
  • Phone: 727-842-8402
  • Fax: 727-841-8060
Mailing address:
  • Phone: 727-842-8402
  • Fax: 727-841-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF15060961
License Number StateFL

VIII. Authorized Official

Name: RAYMOND L TYLER JR.
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential:
Phone: 615-771-7575