Healthcare Provider Details

I. General information

NPI: 1932532942
Provider Name (Legal Business Name): EXTENDED CARE PORTFOLIO TENANT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9015 UNIVERSITY PKWY
PENSACOLA FL
32514-5525
US

IV. Provider business mailing address

13770 58TH ST N SUITE 312
CLEARWATER FL
33760-3759
US

V. Phone/Fax

Practice location:
  • Phone: 850-477-6400
  • Fax:
Mailing address:
  • Phone: 727-726-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL9068
License Number StateFL

VIII. Authorized Official

Name: MINDY MYERS
Title or Position: MANAGER
Credential:
Phone: 727-726-3980