Healthcare Provider Details

I. General information

NPI: 1255333290
Provider Name (Legal Business Name): SCG GRACEWOOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 US HIGHWAY 19 N
PINELLAS PARK FL
33782
US

IV. Provider business mailing address

1240 MARBELLA PLAZA DR
TAMPA FL
33619-7906
US

V. Phone/Fax

Practice location:
  • Phone: 727-541-7515
  • Fax: 727-545-9473
Mailing address:
  • Phone: 813-341-2700
  • Fax: 813-341-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH4155
License Number StateFL

VIII. Authorized Official

Name: MR. KEVIN GOYER
Title or Position: PRESIDENT
Credential:
Phone: 813-341-2700