Healthcare Provider Details

I. General information

NPI: 1487678132
Provider Name (Legal Business Name): 3865 TAMPA ROAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 TAMPA RD
OLDSMAR FL
34677-3008
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 813-855-4661
  • Fax: 813-854-2129
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 1591096
License Number StateFL

VIII. Authorized Official

Name: MICHAEL THEODORE BERG
Title or Position: VP AND ASST SECRETARY
Credential:
Phone: 505-468-4742