Healthcare Provider Details

I. General information

NPI: 1588098263
Provider Name (Legal Business Name): PALM GARDEN OF SUN CITY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 UPPER CREEK DR
RUSKIN FL
33573-6813
US

IV. Provider business mailing address

2033 MAIN ST SUITE 302
SARASOTA FL
34237-6056
US

V. Phone/Fax

Practice location:
  • Phone: 813-633-2875
  • Fax: 813-633-8402
Mailing address:
  • Phone: 941-952-9411
  • Fax: 941-952-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1421096
License Number StateFL

VIII. Authorized Official

Name: MORRIS H. MILLER
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 941-952-9411